"hospital_name","last_updated_on","version","hospital_location","hospital_address","license_number|IA","","To the best of its knowledge and belief, the 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 indicated."
"Guttenberg Municipal Hospital","2025-10-01","2.0.0","Guttenberg Municipal Hospital","200 Main Street, Box 550, Guttenberg, IA  52052-0550","220134H","","true","Disclaimer: The information provided in this machine readable file is to fulfill the CMS requirements for Price Transparency. Charges, allowed amount, cash discounted price, min and max negotiated rates provided in this report are based on claims, remittances and charge master information provided by Guttenberg Municipal Hospital. This was generated on 10/01/2025. All amounts reported may change due to several factors including but not limited to hospital service area where the service is provided, payer contracts and negotiations. This data will be further refined."
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PARTNERS|Commercial|methodology","additional_payer_notes|HEALTH PARTNERS|Commercial","standard_charge|HUMANA|Medicare|negotiated_dollar","standard_charge|HUMANA|Medicare|negotiated_percentage","standard_charge|HUMANA|Medicare|negotiated_algorithm","estimated_amount|HUMANA|Medicare","standard_charge|HUMANA|Medicare|methodology","additional_payer_notes|HUMANA|Medicare","standard_charge|IOWA TOTAL CARE|Medicaid|negotiated_dollar","standard_charge|IOWA TOTAL CARE|Medicaid|negotiated_percentage","standard_charge|IOWA TOTAL CARE|Medicaid|negotiated_algorithm","estimated_amount|IOWA TOTAL CARE|Medicaid","standard_charge|IOWA TOTAL CARE|Medicaid|methodology","additional_payer_notes|IOWA TOTAL CARE|Medicaid","standard_charge|MEDICAL ASSOCIATES|HMO|negotiated_dollar","standard_charge|MEDICAL ASSOCIATES|HMO|negotiated_percentage","standard_charge|MEDICAL ASSOCIATES|HMO|negotiated_algorithm","estimated_amount|MEDICAL ASSOCIATES|HMO","standard_charge|MEDICAL ASSOCIATES|HMO|methodology","additional_payer_notes|MEDICAL ASSOCIATES|HMO","standard_charge|MEDICAL ASSOCIATES|Medicare|negotiated_dollar","standard_charge|MEDICAL ASSOCIATES|Medicare|negotiated_percentage","standard_charge|MEDICAL ASSOCIATES|Medicare|negotiated_algorithm","estimated_amount|MEDICAL ASSOCIATES|Medicare","standard_charge|MEDICAL ASSOCIATES|Medicare|methodology","additional_payer_notes|MEDICAL ASSOCIATES|Medicare","standard_charge|MIDLANDS CHOICE|Commercial|negotiated_dollar","standard_charge|MIDLANDS CHOICE|Commercial|negotiated_percentage","standard_charge|MIDLANDS CHOICE|Commercial|negotiated_algorithm","estimated_amount|MIDLANDS CHOICE|Commercial","standard_charge|MIDLANDS CHOICE|Commercial|methodology","additional_payer_notes|MIDLANDS CHOICE|Commercial","standard_charge|MOLINA|Medicare|negotiated_dollar","standard_charge|MOLINA|Medicare|negotiated_percentage","standard_charge|MOLINA|Medicare|negotiated_algorithm","estimated_amount|MOLINA|Medicare","standard_charge|MOLINA|Medicare|methodology","additional_payer_notes|MOLINA|Medicare","standard_charge|OSCAR|Medicaid|negotiated_dollar","standard_charge|OSCAR|Medicaid|negotiated_percentage","standard_charge|OSCAR|Medicaid|negotiated_algorithm","estimated_amount|OSCAR|Medicaid","standard_charge|OSCAR|Medicaid|methodology","additional_payer_notes|OSCAR|Medicaid","standard_charge|QUARTZ|Commercial|negotiated_dollar","standard_charge|QUARTZ|Commercial|negotiated_percentage","standard_charge|QUARTZ|Commercial|negotiated_algorithm","estimated_amount|QUARTZ|Commercial","standard_charge|QUARTZ|Commercial|methodology","additional_payer_notes|QUARTZ|Commercial","standard_charge|UNITED HEALTHCARE|Commercial|negotiated_dollar","standard_charge|UNITED HEALTHCARE|Commercial|negotiated_percentage","standard_charge|UNITED HEALTHCARE|Commercial|negotiated_algorithm","estimated_amount|UNITED HEALTHCARE|Commercial","standard_charge|UNITED HEALTHCARE|Commercial|methodology","additional_payer_notes|UNITED HEALTHCARE|Commercial","standard_charge|UNITED HEALTHCARE|Medicare|negotiated_dollar","standard_charge|UNITED HEALTHCARE|Medicare|negotiated_percentage","standard_charge|UNITED HEALTHCARE|Medicare|negotiated_algorithm","estimated_amount|UNITED HEALTHCARE|Medicare","standard_charge|UNITED HEALTHCARE|Medicare|methodology","additional_payer_notes|UNITED HEALTHCARE|Medicare","standard_charge|VA|Commercial|negotiated_dollar","standard_charge|VA|Commercial|negotiated_percentage","standard_charge|VA|Commercial|negotiated_algorithm","estimated_amount|VA|Commercial","standard_charge|VA|Commercial|methodology","additional_payer_notes|VA|Commercial","standard_charge|min","standard_charge|max","additional_generic_notes"
"GUIDE CATH FLUID DRAINAGE","10030","CPT","10000223","CDM","360","RC","","Facility","Outpatient","","","1283","1026.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1103.37","86","","","Percent of Total Billed Charges","neg_dollar:$1103.37","898.09","70","","","Percent of Total Billed Charges","neg_dollar:$898.09","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","753.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$753.76;102% of Medicaid interim rate","962.25","75","","","Percent of Total Billed Charges","neg_dollar:$962.25","1103.37","86","","","Percent of Total Billed Charges","neg_dollar:$1103.37","898.09","70","","","Percent of Total Billed Charges","neg_dollar:$898.09","731.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$731.31;103.5% of Medicaid interim rate","1283.00","150","","","Percent of Total Billed Charges","neg_dollar:$1983.58;150% of Medicaid interim rate","1026.40","80","","","Percent of Total Billed Charges","neg_dollar:$1026.40;Percent of Total Billed Charges","1180.36","92","","","Percent of Total Billed Charges","neg_dollar:$1180.36","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","667.00","1283.00",""
"I&D ABSC SMPL OR SGL","10060","CPT","10000075","CDM","761","RC","","Facility","Outpatient","","","446","356.80","446.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","231.92","52","","","Percent of Total Billed Charges","neg_dollar:$231.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","446.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","231.92","52","","","Percent of Total Billed Charges","neg_dollar:$231.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","231.92","52","","","Percent of Total Billed Charges","neg_dollar:$231.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","231.92","52","","","Percent of Total Billed Charges","neg_dollar:$231.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","383.56","86","","","Percent of Total Billed Charges","neg_dollar:$383.56","312.20","70","","","Percent of Total Billed Charges","neg_dollar:$312.20","231.92","52","","","Percent of Total Billed Charges","neg_dollar:$231.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","262.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$262.02;102% of Medicaid interim rate","334.50","75","","","Percent of Total Billed Charges","neg_dollar:$334.50","383.56","86","","","Percent of Total Billed Charges","neg_dollar:$383.56","312.20","70","","","Percent of Total Billed Charges","neg_dollar:$312.20","254.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$254.21;103.5% of Medicaid interim rate","446.00","150","","","Percent of Total Billed Charges","neg_dollar:$689.53;150% of Medicaid interim rate","356.80","80","","","Percent of Total Billed Charges","neg_dollar:$356.80;Percent of Total Billed Charges","410.32","92","","","Percent of Total Billed Charges","neg_dollar:$410.32","231.92","52","","","Percent of Total Billed Charges","neg_dollar:$231.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","231.92","52","","","Percent of Total Billed Charges","neg_dollar:$231.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","231.00","446.00",""
"I&D ABSC COMPL OR MULTI","10061","CPT","10000076","CDM","360","RC","","Facility","Outpatient","","","1259","1007.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","739.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$739.66;102% of Medicaid interim rate","944.25","75","","","Percent of Total Billed Charges","neg_dollar:$944.25","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","717.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$717.62;103.5% of Medicaid interim rate","1259.00","150","","","Percent of Total Billed Charges","neg_dollar:$1946.47;150% of Medicaid interim rate","1007.20","80","","","Percent of Total Billed Charges","neg_dollar:$1007.20;Percent of Total Billed Charges","1158.28","92","","","Percent of Total Billed Charges","neg_dollar:$1158.28","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","654.00","1259.00",""
"I&D PILONID CYS SMPL","10080","CPT","10000002","CDM","360","RC","","Facility","Outpatient","","","2216","1772.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1152.32","52","","","Percent of Total Billed Charges","neg_dollar:$1152.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1152.32","52","","","Percent of Total Billed Charges","neg_dollar:$1152.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1152.32","52","","","Percent of Total Billed Charges","neg_dollar:$1152.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1152.32","52","","","Percent of Total Billed Charges","neg_dollar:$1152.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1905.76","86","","","Percent of Total Billed Charges","neg_dollar:$1905.76","1551.19","70","","","Percent of Total Billed Charges","neg_dollar:$1551.19","1152.32","52","","","Percent of Total Billed Charges","neg_dollar:$1152.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","1301.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$1301.89;102% of Medicaid interim rate","1662.00","75","","","Percent of Total Billed Charges","neg_dollar:$1662","1905.76","86","","","Percent of Total Billed Charges","neg_dollar:$1905.76","1551.19","70","","","Percent of Total Billed Charges","neg_dollar:$1551.19","1263.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$1263.12;103.5% of Medicaid interim rate","2216.00","150","","","Percent of Total Billed Charges","neg_dollar:$3426.04;150% of Medicaid interim rate","1772.80","80","","","Percent of Total Billed Charges","neg_dollar:$1772.80;Percent of Total Billed Charges","2038.72","92","","","Percent of Total Billed Charges","neg_dollar:$2038.72","1152.32","52","","","Percent of Total Billed Charges","neg_dollar:$1152.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","1152.32","52","","","Percent of Total Billed Charges","neg_dollar:$1152.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2216.00",""
"INC & REM FB SQ SMPL","10120","CPT","10000004","CDM","360","RC","","Facility","Outpatient","","","797","637.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","414.44","52","","","Percent of Total Billed Charges","neg_dollar:$414.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","797.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","414.44","52","","","Percent of Total Billed Charges","neg_dollar:$414.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","414.44","52","","","Percent of Total Billed Charges","neg_dollar:$414.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","414.44","52","","","Percent of Total Billed Charges","neg_dollar:$414.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.42","86","","","Percent of Total Billed Charges","neg_dollar:$685.42","557.90","70","","","Percent of Total Billed Charges","neg_dollar:$557.90","414.44","52","","","Percent of Total Billed Charges","neg_dollar:$414.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","468.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$468.23;102% of Medicaid interim rate","597.75","75","","","Percent of Total Billed Charges","neg_dollar:$597.75","685.42","86","","","Percent of Total Billed Charges","neg_dollar:$685.42","557.90","70","","","Percent of Total Billed Charges","neg_dollar:$557.90","454.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$454.28;103.5% of Medicaid interim rate","797.00","150","","","Percent of Total Billed Charges","neg_dollar:$1232.20;150% of Medicaid interim rate","637.60","80","","","Percent of Total Billed Charges","neg_dollar:$637.60;Percent of Total Billed Charges","733.24","92","","","Percent of Total Billed Charges","neg_dollar:$733.24","414.44","52","","","Percent of Total Billed Charges","neg_dollar:$414.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","414.44","52","","","Percent of Total Billed Charges","neg_dollar:$414.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","414.00","797.00",""
"I&D HEMATOMA","10140","CPT","10000077","CDM","360","RC","","Facility","Outpatient","","","3701","2960.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1924.52","52","","","Percent of Total Billed Charges","neg_dollar:$1924.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1924.52","52","","","Percent of Total Billed Charges","neg_dollar:$1924.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1924.52","52","","","Percent of Total Billed Charges","neg_dollar:$1924.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1924.52","52","","","Percent of Total Billed Charges","neg_dollar:$1924.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","3182.86","86","","","Percent of Total Billed Charges","neg_dollar:$3182.86","2590.70","70","","","Percent of Total Billed Charges","neg_dollar:$2590.70","1924.52","52","","","Percent of Total Billed Charges","neg_dollar:$1924.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","2174.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$2174.33;102% of Medicaid interim rate","2775.75","75","","","Percent of Total Billed Charges","neg_dollar:$2775.75","3182.86","86","","","Percent of Total Billed Charges","neg_dollar:$3182.86","2590.70","70","","","Percent of Total Billed Charges","neg_dollar:$2590.70","2109.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$2109.56;103.5% of Medicaid interim rate","3701.00","150","","","Percent of Total Billed Charges","neg_dollar:$5721.93;150% of Medicaid interim rate","2960.80","80","","","Percent of Total Billed Charges","neg_dollar:$2960.80;Percent of Total Billed Charges","3404.92","92","","","Percent of Total Billed Charges","neg_dollar:$3404.92","1924.52","52","","","Percent of Total Billed Charges","neg_dollar:$1924.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1924.52","52","","","Percent of Total Billed Charges","neg_dollar:$1924.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3701.00",""
"PUNCT ASP ABSC HEMAT CYST","10160","CPT","10000078","CDM","360","RC","","Facility","Outpatient","","","1259","1007.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","739.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$739.66;102% of Medicaid interim rate","944.25","75","","","Percent of Total Billed Charges","neg_dollar:$944.25","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","717.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$717.62;103.5% of Medicaid interim rate","1259.00","150","","","Percent of Total Billed Charges","neg_dollar:$1946.47;150% of Medicaid interim rate","1007.20","80","","","Percent of Total Billed Charges","neg_dollar:$1007.20;Percent of Total Billed Charges","1158.28","92","","","Percent of Total Billed Charges","neg_dollar:$1158.28","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","654.00","1259.00",""
"I&D CPLX POSTOP WND INF","10180","CPT","10000079","CDM","360","RC","","Facility","Outpatient","","","6915","5532.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","3595.80","52","","","Percent of Total Billed Charges","neg_dollar:$3595.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","3595.80","52","","","Percent of Total Billed Charges","neg_dollar:$3595.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","3595.80","52","","","Percent of Total Billed Charges","neg_dollar:$3595.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","3595.80","52","","","Percent of Total Billed Charges","neg_dollar:$3595.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","5946.90","86","","","Percent of Total Billed Charges","neg_dollar:$5946.90","4840.50","70","","","Percent of Total Billed Charges","neg_dollar:$4840.50","3595.80","52","","","Percent of Total Billed Charges","neg_dollar:$3595.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","4062.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$4062.55;102% of Medicaid interim rate","5186.25","75","","","Percent of Total Billed Charges","neg_dollar:$5186.25","5946.90","86","","","Percent of Total Billed Charges","neg_dollar:$5946.90","4840.50","70","","","Percent of Total Billed Charges","neg_dollar:$4840.50","3941.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$3941.54;103.5% of Medicaid interim rate","6915.00","150","","","Percent of Total Billed Charges","neg_dollar:$10690.93;150% of Medicaid interim rate","5532.00","80","","","Percent of Total Billed Charges","neg_dollar:$5532;Percent of Total Billed Charges","6361.80","92","","","Percent of Total Billed Charges","neg_dollar:$6361.80","3595.80","52","","","Percent of Total Billed Charges","neg_dollar:$3595.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","3595.80","52","","","Percent of Total Billed Charges","neg_dollar:$3595.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","6915.00",""
"DEBR EXZ/INF SKIN 10% BS","11000","CPT","10000089","CDM","360","RC","","Facility","Outpatient","","","213","170.40","213.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","213.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","183.18","86","","","Percent of Total Billed Charges","neg_dollar:$183.18","149.10","70","","","Percent of Total Billed Charges","neg_dollar:$149.10","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","125.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$125.13;102% of Medicaid interim rate","159.75","75","","","Percent of Total Billed Charges","neg_dollar:$159.75","183.18","86","","","Percent of Total Billed Charges","neg_dollar:$183.18","149.10","70","","","Percent of Total Billed Charges","neg_dollar:$149.10","121.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$121.41;103.5% of Medicaid interim rate","213.00","150","","","Percent of Total Billed Charges","neg_dollar:$329.30;150% of Medicaid interim rate","170.40","80","","","Percent of Total Billed Charges","neg_dollar:$170.40;Percent of Total Billed Charges","195.96","92","","","Percent of Total Billed Charges","neg_dollar:$195.96","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","110.00","213.00",""
"DBRDMT ECZ/INFCT SKN EA ADDL","11001","CPT","10000347","CDM","761","RC","","Facility","Outpatient","","","77","61.60","77.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","40.04","52","","","Percent of Total Billed Charges","neg_dollar:$40.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","77.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","40.04","52","","","Percent of Total Billed Charges","neg_dollar:$40.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","40.04","52","","","Percent of Total Billed Charges","neg_dollar:$40.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","40.04","52","","","Percent of Total Billed Charges","neg_dollar:$40.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","66.22","86","","","Percent of Total Billed Charges","neg_dollar:$66.22","53.90","70","","","Percent of Total Billed Charges","neg_dollar:$53.90","40.04","52","","","Percent of Total Billed Charges","neg_dollar:$40.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","45.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$45.23;102% of Medicaid interim rate","57.75","75","","","Percent of Total Billed Charges","neg_dollar:$57.75","66.22","86","","","Percent of Total Billed Charges","neg_dollar:$66.22","53.90","70","","","Percent of Total Billed Charges","neg_dollar:$53.90","43.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$43.88;103.5% of Medicaid interim rate","77.00","150","","","Percent of Total Billed Charges","neg_dollar:$119.04;150% of Medicaid interim rate","61.60","80","","","Percent of Total Billed Charges","neg_dollar:$61.60;Percent of Total Billed Charges","70.84","92","","","Percent of Total Billed Charges","neg_dollar:$70.84","40.04","52","","","Percent of Total Billed Charges","neg_dollar:$40.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","40.04","52","","","Percent of Total Billed Charges","neg_dollar:$40.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","40.00","77.00",""
"DBRDMT SKIN XTRNL GENT&PER","11004","CPT","10000346","CDM","761","RC","","Facility","Outpatient","","","1791","1432.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","931.32","52","","","Percent of Total Billed Charges","neg_dollar:$931.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","931.32","52","","","Percent of Total Billed Charges","neg_dollar:$931.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","931.32","52","","","Percent of Total Billed Charges","neg_dollar:$931.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","931.32","52","","","Percent of Total Billed Charges","neg_dollar:$931.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1540.26","86","","","Percent of Total Billed Charges","neg_dollar:$1540.26","1253.69","70","","","Percent of Total Billed Charges","neg_dollar:$1253.69","931.32","52","","","Percent of Total Billed Charges","neg_dollar:$931.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","1052.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$1052.21;102% of Medicaid interim rate","1343.25","75","","","Percent of Total Billed Charges","neg_dollar:$1343.25","1540.26","86","","","Percent of Total Billed Charges","neg_dollar:$1540.26","1253.69","70","","","Percent of Total Billed Charges","neg_dollar:$1253.69","1020.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$1020.86;103.5% of Medicaid interim rate","1791.00","150","","","Percent of Total Billed Charges","neg_dollar:$2768.97;150% of Medicaid interim rate","1432.80","80","","","Percent of Total Billed Charges","neg_dollar:$1432.80;Percent of Total Billed Charges","1647.72","92","","","Percent of Total Billed Charges","neg_dollar:$1647.72","931.32","52","","","Percent of Total Billed Charges","neg_dollar:$931.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","931.32","52","","","Percent of Total Billed Charges","neg_dollar:$931.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1791.00",""
"DBRDMT SKIN ABDOMINAL WALL","11005","CPT","10000348","CDM","761","RC","","Facility","Outpatient","","","2441","1952.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1269.32","52","","","Percent of Total Billed Charges","neg_dollar:$1269.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1269.32","52","","","Percent of Total Billed Charges","neg_dollar:$1269.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1269.32","52","","","Percent of Total Billed Charges","neg_dollar:$1269.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1269.32","52","","","Percent of Total Billed Charges","neg_dollar:$1269.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","2099.25","86","","","Percent of Total Billed Charges","neg_dollar:$2099.25","1708.69","70","","","Percent of Total Billed Charges","neg_dollar:$1708.69","1269.32","52","","","Percent of Total Billed Charges","neg_dollar:$1269.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","1434.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1434.08;102% of Medicaid interim rate","1830.75","75","","","Percent of Total Billed Charges","neg_dollar:$1830.75","2099.25","86","","","Percent of Total Billed Charges","neg_dollar:$2099.25","1708.69","70","","","Percent of Total Billed Charges","neg_dollar:$1708.69","1391.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$1391.37;103.5% of Medicaid interim rate","2441.00","150","","","Percent of Total Billed Charges","neg_dollar:$3773.90;150% of Medicaid interim rate","1952.80","80","","","Percent of Total Billed Charges","neg_dollar:$1952.80;Percent of Total Billed Charges","2245.72","92","","","Percent of Total Billed Charges","neg_dollar:$2245.72","1269.32","52","","","Percent of Total Billed Charges","neg_dollar:$1269.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","1269.32","52","","","Percent of Total Billed Charges","neg_dollar:$1269.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2441.00",""
"DBRDMT SKIN XTRNL GENT PER","11006","CPT","10000349","CDM","761","RC","","Facility","Outpatient","","","2209","1767.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1148.68","52","","","Percent of Total Billed Charges","neg_dollar:$1148.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1148.68","52","","","Percent of Total Billed Charges","neg_dollar:$1148.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1148.68","52","","","Percent of Total Billed Charges","neg_dollar:$1148.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1148.68","52","","","Percent of Total Billed Charges","neg_dollar:$1148.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1899.74","86","","","Percent of Total Billed Charges","neg_dollar:$1899.74","1546.30","70","","","Percent of Total Billed Charges","neg_dollar:$1546.30","1148.68","52","","","Percent of Total Billed Charges","neg_dollar:$1148.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","1297.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$1297.78;102% of Medicaid interim rate","1656.75","75","","","Percent of Total Billed Charges","neg_dollar:$1656.75","1899.74","86","","","Percent of Total Billed Charges","neg_dollar:$1899.74","1546.30","70","","","Percent of Total Billed Charges","neg_dollar:$1546.30","1259.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$1259.12;103.5% of Medicaid interim rate","2209.00","150","","","Percent of Total Billed Charges","neg_dollar:$3415.22;150% of Medicaid interim rate","1767.20","80","","","Percent of Total Billed Charges","neg_dollar:$1767.20;Percent of Total Billed Charges","2032.28","92","","","Percent of Total Billed Charges","neg_dollar:$2032.28","1148.68","52","","","Percent of Total Billed Charges","neg_dollar:$1148.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","1148.68","52","","","Percent of Total Billed Charges","neg_dollar:$1148.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2209.00",""
"RMV PRSTC MTRL/MESH ABD WALL","11008","CPT","10000350","CDM","761","RC","","Facility","Outpatient","","","860","688.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","505.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$505.24;102% of Medicaid interim rate","645.00","75","","","Percent of Total Billed Charges","neg_dollar:$645","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","490.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$490.19;103.5% of Medicaid interim rate","860.00","150","","","Percent of Total Billed Charges","neg_dollar:$1329.60;150% of Medicaid interim rate","688.00","80","","","Percent of Total Billed Charges","neg_dollar:$688;Percent of Total Billed Charges","791.20","92","","","Percent of Total Billed Charges","neg_dollar:$791.20","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","447.00","860.00",""
"DEBR W OPEN FX SKIN & SQ","11010","CPT","10000090","CDM","360","RC","","Facility","Outpatient","","","1709","1367.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","888.68","52","","","Percent of Total Billed Charges","neg_dollar:$888.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","888.68","52","","","Percent of Total Billed Charges","neg_dollar:$888.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","888.68","52","","","Percent of Total Billed Charges","neg_dollar:$888.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","888.68","52","","","Percent of Total Billed Charges","neg_dollar:$888.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1469.74","86","","","Percent of Total Billed Charges","neg_dollar:$1469.74","1196.30","70","","","Percent of Total Billed Charges","neg_dollar:$1196.30","888.68","52","","","Percent of Total Billed Charges","neg_dollar:$888.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","1004.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$1004.03;102% of Medicaid interim rate","1281.75","75","","","Percent of Total Billed Charges","neg_dollar:$1281.75","1469.74","86","","","Percent of Total Billed Charges","neg_dollar:$1469.74","1196.30","70","","","Percent of Total Billed Charges","neg_dollar:$1196.30","974.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$974.12;103.5% of Medicaid interim rate","1709.00","150","","","Percent of Total Billed Charges","neg_dollar:$2642.19;150% of Medicaid interim rate","1367.20","80","","","Percent of Total Billed Charges","neg_dollar:$1367.20;Percent of Total Billed Charges","1572.28","92","","","Percent of Total Billed Charges","neg_dollar:$1572.28","888.68","52","","","Percent of Total Billed Charges","neg_dollar:$888.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","888.68","52","","","Percent of Total Billed Charges","neg_dollar:$888.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1709.00",""
"DEBRIDE SKIN MUSC AT FX SITE","11011","CPT","10000227","CDM","450","RC","","Facility","Outpatient","","","1597","1277.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","830.44","52","","","Percent of Total Billed Charges","neg_dollar:$830.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","830.44","52","","","Percent of Total Billed Charges","neg_dollar:$830.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","830.44","52","","","Percent of Total Billed Charges","neg_dollar:$830.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","830.44","52","","","Percent of Total Billed Charges","neg_dollar:$830.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","1373.42","86","","","Percent of Total Billed Charges","neg_dollar:$1373.42","1117.89","70","","","Percent of Total Billed Charges","neg_dollar:$1117.89","830.44","52","","","Percent of Total Billed Charges","neg_dollar:$830.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","938.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$938.23;102% of Medicaid interim rate","1197.75","75","","","Percent of Total Billed Charges","neg_dollar:$1197.75","1373.42","86","","","Percent of Total Billed Charges","neg_dollar:$1373.42","1117.89","70","","","Percent of Total Billed Charges","neg_dollar:$1117.89","910.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$910.29;103.5% of Medicaid interim rate","1597.00","150","","","Percent of Total Billed Charges","neg_dollar:$2469.04;150% of Medicaid interim rate","1277.60","80","","","Percent of Total Billed Charges","neg_dollar:$1277.60;Percent of Total Billed Charges","1469.24","92","","","Percent of Total Billed Charges","neg_dollar:$1469.24","830.44","52","","","Percent of Total Billed Charges","neg_dollar:$830.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","830.44","52","","","Percent of Total Billed Charges","neg_dollar:$830.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1597.00",""
"DEBR O FX SKIN TO BONE","11012","CPT","10000006","CDM","360","RC","","Facility","Outpatient","","","2689","2151.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1398.28","52","","","Percent of Total Billed Charges","neg_dollar:$1398.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1398.28","52","","","Percent of Total Billed Charges","neg_dollar:$1398.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","1398.28","52","","","Percent of Total Billed Charges","neg_dollar:$1398.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","1398.28","52","","","Percent of Total Billed Charges","neg_dollar:$1398.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","2312.54","86","","","Percent of Total Billed Charges","neg_dollar:$2312.54","1882.30","70","","","Percent of Total Billed Charges","neg_dollar:$1882.30","1398.28","52","","","Percent of Total Billed Charges","neg_dollar:$1398.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","1579.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$1579.78;102% of Medicaid interim rate","2016.75","75","","","Percent of Total Billed Charges","neg_dollar:$2016.75","2312.54","86","","","Percent of Total Billed Charges","neg_dollar:$2312.54","1882.30","70","","","Percent of Total Billed Charges","neg_dollar:$1882.30","1532.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$1532.72;103.5% of Medicaid interim rate","2689.00","150","","","Percent of Total Billed Charges","neg_dollar:$4157.32;150% of Medicaid interim rate","2151.20","80","","","Percent of Total Billed Charges","neg_dollar:$2151.20;Percent of Total Billed Charges","2473.88","92","","","Percent of Total Billed Charges","neg_dollar:$2473.88","1398.28","52","","","Percent of Total Billed Charges","neg_dollar:$1398.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","1398.28","52","","","Percent of Total Billed Charges","neg_dollar:$1398.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2689.00",""
"DEBRIDE SKIN TO SQ TISSUE","11042","CPT","10000080","CDM","761","RC","","Facility","Outpatient","","","1259","1007.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","739.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$739.66;102% of Medicaid interim rate","944.25","75","","","Percent of Total Billed Charges","neg_dollar:$944.25","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","717.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$717.62;103.5% of Medicaid interim rate","1259.00","150","","","Percent of Total Billed Charges","neg_dollar:$1946.47;150% of Medicaid interim rate","1007.20","80","","","Percent of Total Billed Charges","neg_dollar:$1007.20;Percent of Total Billed Charges","1158.28","92","","","Percent of Total Billed Charges","neg_dollar:$1158.28","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","654.00","1259.00",""
"DEBRIDE SKIN & MUSCLE","11043","CPT","10000008","CDM","761","RC","","Facility","Outpatient","","","1928","1542.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1002.56","52","","","Percent of Total Billed Charges","neg_dollar:$1002.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1002.56","52","","","Percent of Total Billed Charges","neg_dollar:$1002.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1002.56","52","","","Percent of Total Billed Charges","neg_dollar:$1002.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1002.56","52","","","Percent of Total Billed Charges","neg_dollar:$1002.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1658.08","86","","","Percent of Total Billed Charges","neg_dollar:$1658.08","1349.60","70","","","Percent of Total Billed Charges","neg_dollar:$1349.60","1002.56","52","","","Percent of Total Billed Charges","neg_dollar:$1002.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","1132.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$1132.69;102% of Medicaid interim rate","1446.00","75","","","Percent of Total Billed Charges","neg_dollar:$1446","1658.08","86","","","Percent of Total Billed Charges","neg_dollar:$1658.08","1349.60","70","","","Percent of Total Billed Charges","neg_dollar:$1349.60","1098.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$1098.95;103.5% of Medicaid interim rate","1928.00","150","","","Percent of Total Billed Charges","neg_dollar:$2980.78;150% of Medicaid interim rate","1542.40","80","","","Percent of Total Billed Charges","neg_dollar:$1542.40;Percent of Total Billed Charges","1773.76","92","","","Percent of Total Billed Charges","neg_dollar:$1773.76","1002.56","52","","","Percent of Total Billed Charges","neg_dollar:$1002.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1002.56","52","","","Percent of Total Billed Charges","neg_dollar:$1002.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1928.00",""
"DEBRIDE SKIN & BONE","11044","CPT","10000009","CDM","761","RC","","Facility","Outpatient","","","4054","3243.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2108.08","52","","","Percent of Total Billed Charges","neg_dollar:$2108.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2108.08","52","","","Percent of Total Billed Charges","neg_dollar:$2108.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","2108.08","52","","","Percent of Total Billed Charges","neg_dollar:$2108.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","2108.08","52","","","Percent of Total Billed Charges","neg_dollar:$2108.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","3486.44","86","","","Percent of Total Billed Charges","neg_dollar:$3486.44","2837.79","70","","","Percent of Total Billed Charges","neg_dollar:$2837.79","2108.08","52","","","Percent of Total Billed Charges","neg_dollar:$2108.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","2381.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$2381.72;102% of Medicaid interim rate","3040.50","75","","","Percent of Total Billed Charges","neg_dollar:$3040.50","3486.44","86","","","Percent of Total Billed Charges","neg_dollar:$3486.44","2837.79","70","","","Percent of Total Billed Charges","neg_dollar:$2837.79","2310.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$2310.77;103.5% of Medicaid interim rate","4054.00","150","","","Percent of Total Billed Charges","neg_dollar:$6267.68;150% of Medicaid interim rate","3243.20","80","","","Percent of Total Billed Charges","neg_dollar:$3243.20;Percent of Total Billed Charges","3729.68","92","","","Percent of Total Billed Charges","neg_dollar:$3729.68","2108.08","52","","","Percent of Total Billed Charges","neg_dollar:$2108.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2108.08","52","","","Percent of Total Billed Charges","neg_dollar:$2108.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4054.00",""
"DEB SUBQ TISSUE ADD-ON","11045","CPT","10000010","CDM","761","RC","","Facility","Outpatient","","","1035","828.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","538.20","52","","","Percent of Total Billed Charges","neg_dollar:$538.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","538.20","52","","","Percent of Total Billed Charges","neg_dollar:$538.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","538.20","52","","","Percent of Total Billed Charges","neg_dollar:$538.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","538.20","52","","","Percent of Total Billed Charges","neg_dollar:$538.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","890.10","86","","","Percent of Total Billed Charges","neg_dollar:$890.10","724.50","70","","","Percent of Total Billed Charges","neg_dollar:$724.50","538.20","52","","","Percent of Total Billed Charges","neg_dollar:$538.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","608.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$608.06;102% of Medicaid interim rate","776.25","75","","","Percent of Total Billed Charges","neg_dollar:$776.25","890.10","86","","","Percent of Total Billed Charges","neg_dollar:$890.10","724.50","70","","","Percent of Total Billed Charges","neg_dollar:$724.50","589.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$589.94;103.5% of Medicaid interim rate","1035.00","150","","","Percent of Total Billed Charges","neg_dollar:$1600.16;150% of Medicaid interim rate","828.00","80","","","Percent of Total Billed Charges","neg_dollar:$828;Percent of Total Billed Charges","952.20","92","","","Percent of Total Billed Charges","neg_dollar:$952.20","538.20","52","","","Percent of Total Billed Charges","neg_dollar:$538.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","538.20","52","","","Percent of Total Billed Charges","neg_dollar:$538.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","538.00","1035.00",""
"DEB MUSC/FASCIA ADD-ON","11046","CPT","10000011","CDM","761","RC","","Facility","Outpatient","","","1072","857.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","557.44","52","","","Percent of Total Billed Charges","neg_dollar:$557.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","557.44","52","","","Percent of Total Billed Charges","neg_dollar:$557.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","557.44","52","","","Percent of Total Billed Charges","neg_dollar:$557.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","557.44","52","","","Percent of Total Billed Charges","neg_dollar:$557.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","921.92","86","","","Percent of Total Billed Charges","neg_dollar:$921.92","750.40","70","","","Percent of Total Billed Charges","neg_dollar:$750.40","557.44","52","","","Percent of Total Billed Charges","neg_dollar:$557.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","629.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$629.79;102% of Medicaid interim rate","804.00","75","","","Percent of Total Billed Charges","neg_dollar:$804","921.92","86","","","Percent of Total Billed Charges","neg_dollar:$921.92","750.40","70","","","Percent of Total Billed Charges","neg_dollar:$750.40","611.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$611.04;103.5% of Medicaid interim rate","1072.00","150","","","Percent of Total Billed Charges","neg_dollar:$1657.36;150% of Medicaid interim rate","857.60","80","","","Percent of Total Billed Charges","neg_dollar:$857.60;Percent of Total Billed Charges","986.24","92","","","Percent of Total Billed Charges","neg_dollar:$986.24","557.44","52","","","Percent of Total Billed Charges","neg_dollar:$557.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","557.44","52","","","Percent of Total Billed Charges","neg_dollar:$557.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","557.00","1072.00",""
"DEB BONE ADD-ON","11047","CPT","10000012","CDM","761","RC","","Facility","Outpatient","","","3251","2600.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1690.52","52","","","Percent of Total Billed Charges","neg_dollar:$1690.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1690.52","52","","","Percent of Total Billed Charges","neg_dollar:$1690.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1690.52","52","","","Percent of Total Billed Charges","neg_dollar:$1690.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1690.52","52","","","Percent of Total Billed Charges","neg_dollar:$1690.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","2795.86","86","","","Percent of Total Billed Charges","neg_dollar:$2795.86","2275.70","70","","","Percent of Total Billed Charges","neg_dollar:$2275.70","1690.52","52","","","Percent of Total Billed Charges","neg_dollar:$1690.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","1909.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$1909.95;102% of Medicaid interim rate","2438.25","75","","","Percent of Total Billed Charges","neg_dollar:$2438.25","2795.86","86","","","Percent of Total Billed Charges","neg_dollar:$2795.86","2275.70","70","","","Percent of Total Billed Charges","neg_dollar:$2275.70","1853.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$1853.07;103.5% of Medicaid interim rate","3251.00","150","","","Percent of Total Billed Charges","neg_dollar:$5026.20;150% of Medicaid interim rate","2600.80","80","","","Percent of Total Billed Charges","neg_dollar:$2600.80;Percent of Total Billed Charges","2990.92","92","","","Percent of Total Billed Charges","neg_dollar:$2990.92","1690.52","52","","","Percent of Total Billed Charges","neg_dollar:$1690.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1690.52","52","","","Percent of Total Billed Charges","neg_dollar:$1690.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3251.00",""
"SPL AVULSE NP SGL","11730","CPT","10000083","CDM","360","RC","","Facility","Outpatient","","","509","407.20","509.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","264.68","52","","","Percent of Total Billed Charges","neg_dollar:$264.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","509.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","264.68","52","","","Percent of Total Billed Charges","neg_dollar:$264.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","264.68","52","","","Percent of Total Billed Charges","neg_dollar:$264.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","264.68","52","","","Percent of Total Billed Charges","neg_dollar:$264.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","437.74","86","","","Percent of Total Billed Charges","neg_dollar:$437.74","356.29","70","","","Percent of Total Billed Charges","neg_dollar:$356.29","264.68","52","","","Percent of Total Billed Charges","neg_dollar:$264.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","299.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$299.03;102% of Medicaid interim rate","381.75","75","","","Percent of Total Billed Charges","neg_dollar:$381.75","437.74","86","","","Percent of Total Billed Charges","neg_dollar:$437.74","356.29","70","","","Percent of Total Billed Charges","neg_dollar:$356.29","290.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$290.13;103.5% of Medicaid interim rate","509.00","150","","","Percent of Total Billed Charges","neg_dollar:$786.93;150% of Medicaid interim rate","407.20","80","","","Percent of Total Billed Charges","neg_dollar:$407.20;Percent of Total Billed Charges","468.28","92","","","Percent of Total Billed Charges","neg_dollar:$468.28","264.68","52","","","Percent of Total Billed Charges","neg_dollar:$264.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","264.68","52","","","Percent of Total Billed Charges","neg_dollar:$264.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","264.00","509.00",""
"EVAC SU HEMATOMA","11740","CPT","10000021","CDM","360","RC","","Facility","Outpatient","","","406","324.80","406.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","211.12","52","","","Percent of Total Billed Charges","neg_dollar:$211.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","406.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","211.12","52","","","Percent of Total Billed Charges","neg_dollar:$211.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","211.12","52","","","Percent of Total Billed Charges","neg_dollar:$211.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","211.12","52","","","Percent of Total Billed Charges","neg_dollar:$211.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","349.15","86","","","Percent of Total Billed Charges","neg_dollar:$349.15","284.20","70","","","Percent of Total Billed Charges","neg_dollar:$284.20","211.12","52","","","Percent of Total Billed Charges","neg_dollar:$211.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","238.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$238.52;102% of Medicaid interim rate","304.50","75","","","Percent of Total Billed Charges","neg_dollar:$304.50","349.15","86","","","Percent of Total Billed Charges","neg_dollar:$349.15","284.20","70","","","Percent of Total Billed Charges","neg_dollar:$284.20","231.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$231.42;103.5% of Medicaid interim rate","406.00","150","","","Percent of Total Billed Charges","neg_dollar:$627.69;150% of Medicaid interim rate","324.80","80","","","Percent of Total Billed Charges","neg_dollar:$324.80;Percent of Total Billed Charges","373.52","92","","","Percent of Total Billed Charges","neg_dollar:$373.52","211.12","52","","","Percent of Total Billed Charges","neg_dollar:$211.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","211.12","52","","","Percent of Total Billed Charges","neg_dollar:$211.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","211.00","406.00",""
"REMOVAL OF NAIL BED","11750","CPT","10000022","CDM","360","RC","","Facility","Outpatient","","","1259","1007.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","739.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$739.66;102% of Medicaid interim rate","944.25","75","","","Percent of Total Billed Charges","neg_dollar:$944.25","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","717.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$717.62;103.5% of Medicaid interim rate","1259.00","150","","","Percent of Total Billed Charges","neg_dollar:$1946.47;150% of Medicaid interim rate","1007.20","80","","","Percent of Total Billed Charges","neg_dollar:$1007.20;Percent of Total Billed Charges","1158.28","92","","","Percent of Total Billed Charges","neg_dollar:$1158.28","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","654.00","1259.00",""
"REPAIR NAIL BED","11760","CPT","10000023","CDM","360","RC","","Facility","Outpatient","","","459","367.20","459.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","238.68","52","","","Percent of Total Billed Charges","neg_dollar:$238.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","459.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","238.68","52","","","Percent of Total Billed Charges","neg_dollar:$238.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","238.68","52","","","Percent of Total Billed Charges","neg_dollar:$238.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","238.68","52","","","Percent of Total Billed Charges","neg_dollar:$238.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","394.74","86","","","Percent of Total Billed Charges","neg_dollar:$394.74","321.29","70","","","Percent of Total Billed Charges","neg_dollar:$321.29","238.68","52","","","Percent of Total Billed Charges","neg_dollar:$238.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","269.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$269.66;102% of Medicaid interim rate","344.25","75","","","Percent of Total Billed Charges","neg_dollar:$344.25","394.74","86","","","Percent of Total Billed Charges","neg_dollar:$394.74","321.29","70","","","Percent of Total Billed Charges","neg_dollar:$321.29","261.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$261.63;103.5% of Medicaid interim rate","459.00","150","","","Percent of Total Billed Charges","neg_dollar:$709.63;150% of Medicaid interim rate","367.20","80","","","Percent of Total Billed Charges","neg_dollar:$367.20;Percent of Total Billed Charges","422.28","92","","","Percent of Total Billed Charges","neg_dollar:$422.28","238.68","52","","","Percent of Total Billed Charges","neg_dollar:$238.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","238.68","52","","","Percent of Total Billed Charges","neg_dollar:$238.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","238.00","459.00",""
"INJECTION INTO SKIN LESIONS=<7","11900","CPT","10000117","CDM","761","RC","","Facility","Outpatient","","","445","356.00","445.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","231.40","52","","","Percent of Total Billed Charges","neg_dollar:$231.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","445.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","231.40","52","","","Percent of Total Billed Charges","neg_dollar:$231.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","231.40","52","","","Percent of Total Billed Charges","neg_dollar:$231.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","231.40","52","","","Percent of Total Billed Charges","neg_dollar:$231.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","382.70","86","","","Percent of Total Billed Charges","neg_dollar:$382.70","311.50","70","","","Percent of Total Billed Charges","neg_dollar:$311.50","231.40","52","","","Percent of Total Billed Charges","neg_dollar:$231.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","261.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$261.43;102% of Medicaid interim rate","333.75","75","","","Percent of Total Billed Charges","neg_dollar:$333.75","382.70","86","","","Percent of Total Billed Charges","neg_dollar:$382.70","311.50","70","","","Percent of Total Billed Charges","neg_dollar:$311.50","253.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$253.64;103.5% of Medicaid interim rate","445.00","150","","","Percent of Total Billed Charges","neg_dollar:$687.99;150% of Medicaid interim rate","356.00","80","","","Percent of Total Billed Charges","neg_dollar:$356;Percent of Total Billed Charges","409.40","92","","","Percent of Total Billed Charges","neg_dollar:$409.40","231.40","52","","","Percent of Total Billed Charges","neg_dollar:$231.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","231.40","52","","","Percent of Total Billed Charges","neg_dollar:$231.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","231.00","445.00",""
"SREP S/N/A/G/TR/E 2.5 CM/<","12001","CPT","10000025","CDM","360","RC","","Facility","Outpatient","","","293","234.40","293.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","152.36","52","","","Percent of Total Billed Charges","neg_dollar:$152.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","293.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","152.36","52","","","Percent of Total Billed Charges","neg_dollar:$152.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","152.36","52","","","Percent of Total Billed Charges","neg_dollar:$152.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","152.36","52","","","Percent of Total Billed Charges","neg_dollar:$152.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","251.98","86","","","Percent of Total Billed Charges","neg_dollar:$251.98","205.10","70","","","Percent of Total Billed Charges","neg_dollar:$205.10","152.36","52","","","Percent of Total Billed Charges","neg_dollar:$152.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","172.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$172.13;102% of Medicaid interim rate","219.75","75","","","Percent of Total Billed Charges","neg_dollar:$219.75","251.98","86","","","Percent of Total Billed Charges","neg_dollar:$251.98","205.10","70","","","Percent of Total Billed Charges","neg_dollar:$205.10","167.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$167.01;103.5% of Medicaid interim rate","293.00","150","","","Percent of Total Billed Charges","neg_dollar:$452.99;150% of Medicaid interim rate","234.40","80","","","Percent of Total Billed Charges","neg_dollar:$234.40;Percent of Total Billed Charges","269.56","92","","","Percent of Total Billed Charges","neg_dollar:$269.56","152.36","52","","","Percent of Total Billed Charges","neg_dollar:$152.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","152.36","52","","","Percent of Total Billed Charges","neg_dollar:$152.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","152.00","293.00",""
"SREP S/N/A/G/TR/E 2.6-7.5 CM","12002","CPT","10000026","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"SREP S/N/A/G/TR/E 7.6-12.5 CM","12004","CPT","10000027","CDM","360","RC","","Facility","Outpatient","","","284","227.20","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","166.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$166.84;102% of Medicaid interim rate","213.00","75","","","Percent of Total Billed Charges","neg_dollar:$213","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","161.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$161.88;103.5% of Medicaid interim rate","284.00","150","","","Percent of Total Billed Charges","neg_dollar:$439.07;150% of Medicaid interim rate","227.20","80","","","Percent of Total Billed Charges","neg_dollar:$227.20;Percent of Total Billed Charges","261.28","92","","","Percent of Total Billed Charges","neg_dollar:$261.28","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.00","284.00",""
"SREP S/N/A/G/TR/E 12.6-20.0 CM","12005","CPT","10000028","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"SREP S/N/A/G/TR/E 20.1-30.0 CM","12006","CPT","10000029","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"SREP F/E/N/L/MM 2.5 CM/<","12011","CPT","10000031","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"SREP F/E/N/L/MM 2.6-5.0 CM","12013","CPT","10000032","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"SREP F/E/N/L/MM 5.1-7.5 CM","12014","CPT","10000033","CDM","360","RC","","Facility","Outpatient","","","284","227.20","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","166.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$166.84;102% of Medicaid interim rate","213.00","75","","","Percent of Total Billed Charges","neg_dollar:$213","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","161.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$161.88;103.5% of Medicaid interim rate","284.00","150","","","Percent of Total Billed Charges","neg_dollar:$439.07;150% of Medicaid interim rate","227.20","80","","","Percent of Total Billed Charges","neg_dollar:$227.20;Percent of Total Billed Charges","261.28","92","","","Percent of Total Billed Charges","neg_dollar:$261.28","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.00","284.00",""
"SREP F/E/N/L/MM 7.6-12.5 CM","12015","CPT","10000034","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"TX S WND DEHISC SMPL","12020","CPT","10000037","CDM","360","RC","","Facility","Outpatient","","","1602","1281.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","833.04","52","","","Percent of Total Billed Charges","neg_dollar:$833.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","833.04","52","","","Percent of Total Billed Charges","neg_dollar:$833.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","833.04","52","","","Percent of Total Billed Charges","neg_dollar:$833.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","833.04","52","","","Percent of Total Billed Charges","neg_dollar:$833.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1377.72","86","","","Percent of Total Billed Charges","neg_dollar:$1377.72","1121.39","70","","","Percent of Total Billed Charges","neg_dollar:$1121.39","833.04","52","","","Percent of Total Billed Charges","neg_dollar:$833.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","941.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$941.17;102% of Medicaid interim rate","1201.50","75","","","Percent of Total Billed Charges","neg_dollar:$1201.50","1377.72","86","","","Percent of Total Billed Charges","neg_dollar:$1377.72","1121.39","70","","","Percent of Total Billed Charges","neg_dollar:$1121.39","913.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$913.13;103.5% of Medicaid interim rate","1602.00","150","","","Percent of Total Billed Charges","neg_dollar:$2476.77;150% of Medicaid interim rate","1281.60","80","","","Percent of Total Billed Charges","neg_dollar:$1281.60;Percent of Total Billed Charges","1473.84","92","","","Percent of Total Billed Charges","neg_dollar:$1473.84","833.04","52","","","Percent of Total Billed Charges","neg_dollar:$833.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","833.04","52","","","Percent of Total Billed Charges","neg_dollar:$833.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1602.00",""
"INT REP S/A/T/EX 2.5 CM/<","12031","CPT","10000039","CDM","360","RC","","Facility","Outpatient","","","564","451.20","564.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","564.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","331.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$331.34;102% of Medicaid interim rate","423.00","75","","","Percent of Total Billed Charges","neg_dollar:$423","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","321.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$321.47;103.5% of Medicaid interim rate","564.00","150","","","Percent of Total Billed Charges","neg_dollar:$871.97;150% of Medicaid interim rate","451.20","80","","","Percent of Total Billed Charges","neg_dollar:$451.20;Percent of Total Billed Charges","518.88","92","","","Percent of Total Billed Charges","neg_dollar:$518.88","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","293.00","564.00",""
"INT REP S/A/T/EX 2.6-7.5 CM","12032","CPT","10000040","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"INT REP S/A/T/EX 7.6-12.5 CM","12034","CPT","10000041","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"INT REP S/A/T/EX 12.6-20.0 CM","12035","CPT","10000042","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"INT REP N/H/F/G 2.5 CM/<","12041","CPT","10000045","CDM","360","RC","","Facility","Outpatient","","","485","388.00","485.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","252.20","52","","","Percent of Total Billed Charges","neg_dollar:$252.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","485.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","252.20","52","","","Percent of Total Billed Charges","neg_dollar:$252.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","252.20","52","","","Percent of Total Billed Charges","neg_dollar:$252.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","252.20","52","","","Percent of Total Billed Charges","neg_dollar:$252.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","417.09","86","","","Percent of Total Billed Charges","neg_dollar:$417.09","339.50","70","","","Percent of Total Billed Charges","neg_dollar:$339.50","252.20","52","","","Percent of Total Billed Charges","neg_dollar:$252.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","284.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$284.93;102% of Medicaid interim rate","363.75","75","","","Percent of Total Billed Charges","neg_dollar:$363.75","417.09","86","","","Percent of Total Billed Charges","neg_dollar:$417.09","339.50","70","","","Percent of Total Billed Charges","neg_dollar:$339.50","276.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$276.45;103.5% of Medicaid interim rate","485.00","150","","","Percent of Total Billed Charges","neg_dollar:$749.83;150% of Medicaid interim rate","388.00","80","","","Percent of Total Billed Charges","neg_dollar:$388;Percent of Total Billed Charges","446.20","92","","","Percent of Total Billed Charges","neg_dollar:$446.20","252.20","52","","","Percent of Total Billed Charges","neg_dollar:$252.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","252.20","52","","","Percent of Total Billed Charges","neg_dollar:$252.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","252.00","485.00",""
"INT REP N/H/F/G 2.6-7.5 CM","12042","CPT","10000046","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"INT REP N/H/F/G 7.6-12.5 CM","12044","CPT","10000047","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"INT REP F/E/N/L/MM 2.5 CM/<","12051","CPT","10000051","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"INT REP F/E/N/L/MM 2.6-5.0 CM","12052","CPT","10000052","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"INT REP F/E/N/L/MM 5.1-7.5 CM","12053","CPT","10000053","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"INT REP F/E/N/L/MM 7.6-12.5 CM","12054","CPT","10000054","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"INT REP F/E/N/L/MM 12.6-20.0 CM","12055","CPT","10000055","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"CREP S/A/L 2.6-7.5 CM","13121","CPT","10000059","CDM","360","RC","","Facility","Outpatient","","","867","693.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","450.84","52","","","Percent of Total Billed Charges","neg_dollar:$450.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","450.84","52","","","Percent of Total Billed Charges","neg_dollar:$450.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","450.84","52","","","Percent of Total Billed Charges","neg_dollar:$450.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","450.84","52","","","Percent of Total Billed Charges","neg_dollar:$450.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","745.62","86","","","Percent of Total Billed Charges","neg_dollar:$745.62","606.90","70","","","Percent of Total Billed Charges","neg_dollar:$606.90","450.84","52","","","Percent of Total Billed Charges","neg_dollar:$450.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","509.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$509.36;102% of Medicaid interim rate","650.25","75","","","Percent of Total Billed Charges","neg_dollar:$650.25","745.62","86","","","Percent of Total Billed Charges","neg_dollar:$745.62","606.90","70","","","Percent of Total Billed Charges","neg_dollar:$606.90","494.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$494.18;103.5% of Medicaid interim rate","867.00","150","","","Percent of Total Billed Charges","neg_dollar:$1340.42;150% of Medicaid interim rate","693.60","80","","","Percent of Total Billed Charges","neg_dollar:$693.60;Percent of Total Billed Charges","797.64","92","","","Percent of Total Billed Charges","neg_dollar:$797.64","450.84","52","","","Percent of Total Billed Charges","neg_dollar:$450.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","450.84","52","","","Percent of Total Billed Charges","neg_dollar:$450.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","450.00","867.00",""
"CREP F/G/H/F 1.1-2.5 CM","13131","CPT","10000061","CDM","360","RC","","Facility","Outpatient","","","942","753.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","489.84","52","","","Percent of Total Billed Charges","neg_dollar:$489.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","489.84","52","","","Percent of Total Billed Charges","neg_dollar:$489.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","489.84","52","","","Percent of Total Billed Charges","neg_dollar:$489.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","489.84","52","","","Percent of Total Billed Charges","neg_dollar:$489.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","810.12","86","","","Percent of Total Billed Charges","neg_dollar:$810.12","659.40","70","","","Percent of Total Billed Charges","neg_dollar:$659.40","489.84","52","","","Percent of Total Billed Charges","neg_dollar:$489.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","553.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$553.42;102% of Medicaid interim rate","706.50","75","","","Percent of Total Billed Charges","neg_dollar:$706.50","810.12","86","","","Percent of Total Billed Charges","neg_dollar:$810.12","659.40","70","","","Percent of Total Billed Charges","neg_dollar:$659.40","536.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$536.93;103.5% of Medicaid interim rate","942.00","150","","","Percent of Total Billed Charges","neg_dollar:$1456.37;150% of Medicaid interim rate","753.60","80","","","Percent of Total Billed Charges","neg_dollar:$753.60;Percent of Total Billed Charges","866.64","92","","","Percent of Total Billed Charges","neg_dollar:$866.64","489.84","52","","","Percent of Total Billed Charges","neg_dollar:$489.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","489.84","52","","","Percent of Total Billed Charges","neg_dollar:$489.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","489.00","942.00",""
"CREP F/G/H/F 2.6-7.5 CM","13132","CPT","10000062","CDM","360","RC","","Facility","Outpatient","","","564","451.20","564.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","564.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","331.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$331.34;102% of Medicaid interim rate","423.00","75","","","Percent of Total Billed Charges","neg_dollar:$423","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","321.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$321.47;103.5% of Medicaid interim rate","564.00","150","","","Percent of Total Billed Charges","neg_dollar:$871.97;150% of Medicaid interim rate","451.20","80","","","Percent of Total Billed Charges","neg_dollar:$451.20;Percent of Total Billed Charges","518.88","92","","","Percent of Total Billed Charges","neg_dollar:$518.88","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","293.00","564.00",""
"CREP F/G/H/F EA ADD 5 CM/<","13133","CPT","10000063","CDM","360","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"CREP E/N/E/L 1.1-2.5 CM","13151","CPT","10000065","CDM","360","RC","","Facility","Outpatient","","","1098","878.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","944.28","86","","","Percent of Total Billed Charges","neg_dollar:$944.28","768.59","70","","","Percent of Total Billed Charges","neg_dollar:$768.59","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","645.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$645.07;102% of Medicaid interim rate","823.50","75","","","Percent of Total Billed Charges","neg_dollar:$823.50","944.28","86","","","Percent of Total Billed Charges","neg_dollar:$944.28","768.59","70","","","Percent of Total Billed Charges","neg_dollar:$768.59","625.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$625.85;103.5% of Medicaid interim rate","1098.00","150","","","Percent of Total Billed Charges","neg_dollar:$1697.56;150% of Medicaid interim rate","878.40","80","","","Percent of Total Billed Charges","neg_dollar:$878.40;Percent of Total Billed Charges","1010.16","92","","","Percent of Total Billed Charges","neg_dollar:$1010.16","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","570.00","1098.00",""
"CREP E/N/E/L 2.6-7.5 CM","13152","CPT","10000066","CDM","360","RC","","Facility","Outpatient","","","1299","1039.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","675.48","52","","","Percent of Total Billed Charges","neg_dollar:$675.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","675.48","52","","","Percent of Total Billed Charges","neg_dollar:$675.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","675.48","52","","","Percent of Total Billed Charges","neg_dollar:$675.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","675.48","52","","","Percent of Total Billed Charges","neg_dollar:$675.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1117.13","86","","","Percent of Total Billed Charges","neg_dollar:$1117.13","909.30","70","","","Percent of Total Billed Charges","neg_dollar:$909.30","675.48","52","","","Percent of Total Billed Charges","neg_dollar:$675.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","763.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$763.16;102% of Medicaid interim rate","974.25","75","","","Percent of Total Billed Charges","neg_dollar:$974.25","1117.13","86","","","Percent of Total Billed Charges","neg_dollar:$1117.13","909.30","70","","","Percent of Total Billed Charges","neg_dollar:$909.30","740.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$740.43;103.5% of Medicaid interim rate","1299.00","150","","","Percent of Total Billed Charges","neg_dollar:$2008.31;150% of Medicaid interim rate","1039.20","80","","","Percent of Total Billed Charges","neg_dollar:$1039.20;Percent of Total Billed Charges","1195.08","92","","","Percent of Total Billed Charges","neg_dollar:$1195.08","675.48","52","","","Percent of Total Billed Charges","neg_dollar:$675.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","675.48","52","","","Percent of Total Billed Charges","neg_dollar:$675.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","675.00","1299.00",""
"WOUND PREP TRNK/ARM/LEG 100 SQ CM/1% BA","15002","CPT","10000160","CDM","761","RC","","Facility","Outpatient","","","4712","3769.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2450.24","52","","","Percent of Total Billed Charges","neg_dollar:$2450.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2450.24","52","","","Percent of Total Billed Charges","neg_dollar:$2450.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2450.24","52","","","Percent of Total Billed Charges","neg_dollar:$2450.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2450.24","52","","","Percent of Total Billed Charges","neg_dollar:$2450.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","4052.32","86","","","Percent of Total Billed Charges","neg_dollar:$4052.32","3298.39","70","","","Percent of Total Billed Charges","neg_dollar:$3298.39","2450.24","52","","","Percent of Total Billed Charges","neg_dollar:$2450.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","2768.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$2768.29;102% of Medicaid interim rate","3534.00","75","","","Percent of Total Billed Charges","neg_dollar:$3534","4052.32","86","","","Percent of Total Billed Charges","neg_dollar:$4052.32","3298.39","70","","","Percent of Total Billed Charges","neg_dollar:$3298.39","2685.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$2685.83;103.5% of Medicaid interim rate","4712.00","150","","","Percent of Total Billed Charges","neg_dollar:$7284.98;150% of Medicaid interim rate","3769.60","80","","","Percent of Total Billed Charges","neg_dollar:$3769.60;Percent of Total Billed Charges","4335.04","92","","","Percent of Total Billed Charges","neg_dollar:$4335.04","2450.24","52","","","Percent of Total Billed Charges","neg_dollar:$2450.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","2450.24","52","","","Percent of Total Billed Charges","neg_dollar:$2450.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4712.00",""
"WOUND PREP F/N/HF/G 100 SQ CM/1% BA","15004","CPT","10000068","CDM","761","RC","","Facility","Outpatient","","","1601","1280.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","832.52","52","","","Percent of Total Billed Charges","neg_dollar:$832.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","832.52","52","","","Percent of Total Billed Charges","neg_dollar:$832.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","832.52","52","","","Percent of Total Billed Charges","neg_dollar:$832.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","832.52","52","","","Percent of Total Billed Charges","neg_dollar:$832.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1376.86","86","","","Percent of Total Billed Charges","neg_dollar:$1376.86","1120.69","70","","","Percent of Total Billed Charges","neg_dollar:$1120.69","832.52","52","","","Percent of Total Billed Charges","neg_dollar:$832.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","940.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$940.58;102% of Medicaid interim rate","1200.75","75","","","Percent of Total Billed Charges","neg_dollar:$1200.75","1376.86","86","","","Percent of Total Billed Charges","neg_dollar:$1376.86","1120.69","70","","","Percent of Total Billed Charges","neg_dollar:$1120.69","912.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$912.56;103.5% of Medicaid interim rate","1601.00","150","","","Percent of Total Billed Charges","neg_dollar:$2475.22;150% of Medicaid interim rate","1280.80","80","","","Percent of Total Billed Charges","neg_dollar:$1280.80;Percent of Total Billed Charges","1472.92","92","","","Percent of Total Billed Charges","neg_dollar:$1472.92","832.52","52","","","Percent of Total Billed Charges","neg_dollar:$832.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","832.52","52","","","Percent of Total Billed Charges","neg_dollar:$832.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1601.00",""
"SKIN FULL GRFT FACE/GENIT/HF =< 20 SQ CM","15240","CPT","10000165","CDM","761","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"SKIN SUB GRAFT T/A/L 25 SQ CM","15271","CPT","10000130","CDM","761","RC","","Facility","Outpatient","","","4937","3949.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","2900.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$2900.48;102% of Medicaid interim rate","3702.75","75","","","Percent of Total Billed Charges","neg_dollar:$3702.75","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","2814.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$2814.08;103.5% of Medicaid interim rate","4937.00","150","","","Percent of Total Billed Charges","neg_dollar:$7632.84;150% of Medicaid interim rate","3949.60","80","","","Percent of Total Billed Charges","neg_dollar:$3949.60;Percent of Total Billed Charges","4542.04","92","","","Percent of Total Billed Charges","neg_dollar:$4542.04","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4937.00",""
"SKIN SUB GRAFT T/A/L ADD 25 SQ CM","15272","CPT","10000131","CDM","761","RC","","Facility","Outpatient","","","4413","3530.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","2592.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$2592.63;102% of Medicaid interim rate","3309.75","75","","","Percent of Total Billed Charges","neg_dollar:$3309.75","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","2515.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$2515.41;103.5% of Medicaid interim rate","4413.00","150","","","Percent of Total Billed Charges","neg_dollar:$6822.71;150% of Medicaid interim rate","3530.40","80","","","Percent of Total Billed Charges","neg_dollar:$3530.40;Percent of Total Billed Charges","4059.96","92","","","Percent of Total Billed Charges","neg_dollar:$4059.96","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4413.00",""
"SKIN SUB GRFT T/A/L CHILD 100 SQ CM","15273","CPT","10000132","CDM","761","RC","","Facility","Outpatient","","","9610","7688.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","4997.20","52","","","Percent of Total Billed Charges","neg_dollar:$4997.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","4997.20","52","","","Percent of Total Billed Charges","neg_dollar:$4997.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","4997.20","52","","","Percent of Total Billed Charges","neg_dollar:$4997.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","4997.20","52","","","Percent of Total Billed Charges","neg_dollar:$4997.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","8264.60","86","","","Percent of Total Billed Charges","neg_dollar:$8264.60","6727.00","70","","","Percent of Total Billed Charges","neg_dollar:$6727","4997.20","52","","","Percent of Total Billed Charges","neg_dollar:$4997.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","5645.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$5645.86;102% of Medicaid interim rate","7207.50","75","","","Percent of Total Billed Charges","neg_dollar:$7207.50","8264.60","86","","","Percent of Total Billed Charges","neg_dollar:$8264.60","6727.00","70","","","Percent of Total Billed Charges","neg_dollar:$6727","5477.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$5477.70;103.5% of Medicaid interim rate","9610.00","150","","","Percent of Total Billed Charges","neg_dollar:$14857.54;150% of Medicaid interim rate","7688.00","80","","","Percent of Total Billed Charges","neg_dollar:$7688;Percent of Total Billed Charges","8841.20","92","","","Percent of Total Billed Charges","neg_dollar:$8841.20","4997.20","52","","","Percent of Total Billed Charges","neg_dollar:$4997.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","4997.20","52","","","Percent of Total Billed Charges","neg_dollar:$4997.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","9610.00",""
"SKIN SUB GRFT T/A/L CH ADD 100 SQ CM","15274","CPT","10000133","CDM","761","RC","","Facility","Outpatient","","","9085","7268.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","4724.20","52","","","Percent of Total Billed Charges","neg_dollar:$4724.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","4724.20","52","","","Percent of Total Billed Charges","neg_dollar:$4724.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","4724.20","52","","","Percent of Total Billed Charges","neg_dollar:$4724.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","4724.20","52","","","Percent of Total Billed Charges","neg_dollar:$4724.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","7813.09","86","","","Percent of Total Billed Charges","neg_dollar:$7813.09","6359.50","70","","","Percent of Total Billed Charges","neg_dollar:$6359.50","4724.20","52","","","Percent of Total Billed Charges","neg_dollar:$4724.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","5337.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$5337.42;102% of Medicaid interim rate","6813.75","75","","","Percent of Total Billed Charges","neg_dollar:$6813.75","7813.09","86","","","Percent of Total Billed Charges","neg_dollar:$7813.09","6359.50","70","","","Percent of Total Billed Charges","neg_dollar:$6359.50","5178.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$5178.45;103.5% of Medicaid interim rate","9085.00","150","","","Percent of Total Billed Charges","neg_dollar:$14045.86;150% of Medicaid interim rate","7268.00","80","","","Percent of Total Billed Charges","neg_dollar:$7268;Percent of Total Billed Charges","8358.20","92","","","Percent of Total Billed Charges","neg_dollar:$8358.20","4724.20","52","","","Percent of Total Billed Charges","neg_dollar:$4724.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","4724.20","52","","","Percent of Total Billed Charges","neg_dollar:$4724.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","9085.00",""
"SKIN SUB GRFT F/NK/HF/G 25 SQ CM","15275","CPT","10000134","CDM","761","RC","","Facility","Outpatient","","","4937","3949.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","2900.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$2900.48;102% of Medicaid interim rate","3702.75","75","","","Percent of Total Billed Charges","neg_dollar:$3702.75","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","2814.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$2814.08;103.5% of Medicaid interim rate","4937.00","150","","","Percent of Total Billed Charges","neg_dollar:$7632.84;150% of Medicaid interim rate","3949.60","80","","","Percent of Total Billed Charges","neg_dollar:$3949.60;Percent of Total Billed Charges","4542.04","92","","","Percent of Total Billed Charges","neg_dollar:$4542.04","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4937.00",""
"SKIN SUB GRFT F/NK/HF/G ADD 25 SQ CM","15276","CPT","10000135","CDM","761","RC","","Facility","Outpatient","","","4413","3530.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","2592.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$2592.63;102% of Medicaid interim rate","3309.75","75","","","Percent of Total Billed Charges","neg_dollar:$3309.75","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","2515.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$2515.41;103.5% of Medicaid interim rate","4413.00","150","","","Percent of Total Billed Charges","neg_dollar:$6822.71;150% of Medicaid interim rate","3530.40","80","","","Percent of Total Billed Charges","neg_dollar:$3530.40;Percent of Total Billed Charges","4059.96","92","","","Percent of Total Billed Charges","neg_dollar:$4059.96","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4413.00",""
"SKN SUB GRFT F/NK/HF/G CHILD 100 SQ CM","15277","CPT","10000136","CDM","761","RC","","Facility","Outpatient","","","4937","3949.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","2900.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$2900.48;102% of Medicaid interim rate","3702.75","75","","","Percent of Total Billed Charges","neg_dollar:$3702.75","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","2814.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$2814.08;103.5% of Medicaid interim rate","4937.00","150","","","Percent of Total Billed Charges","neg_dollar:$7632.84;150% of Medicaid interim rate","3949.60","80","","","Percent of Total Billed Charges","neg_dollar:$3949.60;Percent of Total Billed Charges","4542.04","92","","","Percent of Total Billed Charges","neg_dollar:$4542.04","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","2567.24","52","","","Percent of Total Billed Charges","neg_dollar:$2567.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4937.00",""
"SKN SUB GRFT F/NK/HF/G CH ADD 100 SQ CM","15278","CPT","10000137","CDM","761","RC","","Facility","Outpatient","","","4413","3530.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","2592.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$2592.63;102% of Medicaid interim rate","3309.75","75","","","Percent of Total Billed Charges","neg_dollar:$3309.75","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","2515.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$2515.41;103.5% of Medicaid interim rate","4413.00","150","","","Percent of Total Billed Charges","neg_dollar:$6822.71;150% of Medicaid interim rate","3530.40","80","","","Percent of Total Billed Charges","neg_dollar:$3530.40;Percent of Total Billed Charges","4059.96","92","","","Percent of Total Billed Charges","neg_dollar:$4059.96","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","2294.76","52","","","Percent of Total Billed Charges","neg_dollar:$2294.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4413.00",""
"DRESS/DEBRID P-THICK BURN M 5-10%","16025","CPT","10000086","CDM","360","RC","","Facility","Outpatient","","","440","352.00","440.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","440.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","378.40","86","","","Percent of Total Billed Charges","neg_dollar:$378.40","308.00","70","","","Percent of Total Billed Charges","neg_dollar:$308","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","258.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$258.49;102% of Medicaid interim rate","330.00","75","","","Percent of Total Billed Charges","neg_dollar:$330","378.40","86","","","Percent of Total Billed Charges","neg_dollar:$378.40","308.00","70","","","Percent of Total Billed Charges","neg_dollar:$308","250.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$250.79;103.5% of Medicaid interim rate","440.00","150","","","Percent of Total Billed Charges","neg_dollar:$680.26;150% of Medicaid interim rate","352.00","80","","","Percent of Total Billed Charges","neg_dollar:$352;Percent of Total Billed Charges","404.80","92","","","Percent of Total Billed Charges","neg_dollar:$404.80","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","228.00","440.00",""
"CHEM CAUT GRANULATION TISS","17250","CPT","10000088","CDM","761","RC","","Facility","Outpatient","","","354","283.20","354.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","184.08","52","","","Percent of Total Billed Charges","neg_dollar:$184.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","354.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","184.08","52","","","Percent of Total Billed Charges","neg_dollar:$184.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.08","52","","","Percent of Total Billed Charges","neg_dollar:$184.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.08","52","","","Percent of Total Billed Charges","neg_dollar:$184.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","304.44","86","","","Percent of Total Billed Charges","neg_dollar:$304.44","247.79","70","","","Percent of Total Billed Charges","neg_dollar:$247.79","184.08","52","","","Percent of Total Billed Charges","neg_dollar:$184.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","207.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$207.97;102% of Medicaid interim rate","265.50","75","","","Percent of Total Billed Charges","neg_dollar:$265.50","304.44","86","","","Percent of Total Billed Charges","neg_dollar:$304.44","247.79","70","","","Percent of Total Billed Charges","neg_dollar:$247.79","201.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$201.77;103.5% of Medicaid interim rate","354.00","150","","","Percent of Total Billed Charges","neg_dollar:$547.30;150% of Medicaid interim rate","283.20","80","","","Percent of Total Billed Charges","neg_dollar:$283.20;Percent of Total Billed Charges","325.68","92","","","Percent of Total Billed Charges","neg_dollar:$325.68","184.08","52","","","Percent of Total Billed Charges","neg_dollar:$184.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.08","52","","","Percent of Total Billed Charges","neg_dollar:$184.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.00","354.00",""
"PUNCT ASP BREAST CYST INITIAL","19000","CPT","10000105","CDM","360","RC","","Facility","Outpatient","","","853","682.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","443.56","52","","","Percent of Total Billed Charges","neg_dollar:$443.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","443.56","52","","","Percent of Total Billed Charges","neg_dollar:$443.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","443.56","52","","","Percent of Total Billed Charges","neg_dollar:$443.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","443.56","52","","","Percent of Total Billed Charges","neg_dollar:$443.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","733.58","86","","","Percent of Total Billed Charges","neg_dollar:$733.58","597.09","70","","","Percent of Total Billed Charges","neg_dollar:$597.09","443.56","52","","","Percent of Total Billed Charges","neg_dollar:$443.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","501.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$501.13;102% of Medicaid interim rate","639.75","75","","","Percent of Total Billed Charges","neg_dollar:$639.75","733.58","86","","","Percent of Total Billed Charges","neg_dollar:$733.58","597.09","70","","","Percent of Total Billed Charges","neg_dollar:$597.09","486.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$486.21;103.5% of Medicaid interim rate","853.00","150","","","Percent of Total Billed Charges","neg_dollar:$1318.78;150% of Medicaid interim rate","682.40","80","","","Percent of Total Billed Charges","neg_dollar:$682.40;Percent of Total Billed Charges","784.76","92","","","Percent of Total Billed Charges","neg_dollar:$784.76","443.56","52","","","Percent of Total Billed Charges","neg_dollar:$443.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","443.56","52","","","Percent of Total Billed Charges","neg_dollar:$443.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","443.00","853.00",""
"PUNCT ASP BREAST CYST EA ADDTL","19001","CPT","10000106","CDM","360","RC","","Facility","Outpatient","","","333","266.40","333.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","173.16","52","","","Percent of Total Billed Charges","neg_dollar:$173.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","333.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","173.16","52","","","Percent of Total Billed Charges","neg_dollar:$173.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","173.16","52","","","Percent of Total Billed Charges","neg_dollar:$173.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","173.16","52","","","Percent of Total Billed Charges","neg_dollar:$173.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","286.38","86","","","Percent of Total Billed Charges","neg_dollar:$286.38","233.10","70","","","Percent of Total Billed Charges","neg_dollar:$233.10","173.16","52","","","Percent of Total Billed Charges","neg_dollar:$173.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","195.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$195.63;102% of Medicaid interim rate","249.75","75","","","Percent of Total Billed Charges","neg_dollar:$249.75","286.38","86","","","Percent of Total Billed Charges","neg_dollar:$286.38","233.10","70","","","Percent of Total Billed Charges","neg_dollar:$233.10","189.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$189.80;103.5% of Medicaid interim rate","333.00","150","","","Percent of Total Billed Charges","neg_dollar:$514.83;150% of Medicaid interim rate","266.40","80","","","Percent of Total Billed Charges","neg_dollar:$266.40;Percent of Total Billed Charges","306.36","92","","","Percent of Total Billed Charges","neg_dollar:$306.36","173.16","52","","","Percent of Total Billed Charges","neg_dollar:$173.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","173.16","52","","","Percent of Total Billed Charges","neg_dollar:$173.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","173.00","333.00",""
"INJ MAMMARY DUCT","19030","CPT","10000107","CDM","360","RC","","Facility","Outpatient","","","431","344.80","431.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","431.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","370.65","86","","","Percent of Total Billed Charges","neg_dollar:$370.65","301.70","70","","","Percent of Total Billed Charges","neg_dollar:$301.70","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","253.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$253.21;102% of Medicaid interim rate","323.25","75","","","Percent of Total Billed Charges","neg_dollar:$323.25","370.65","86","","","Percent of Total Billed Charges","neg_dollar:$370.65","301.70","70","","","Percent of Total Billed Charges","neg_dollar:$301.70","245.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$245.67;103.5% of Medicaid interim rate","431.00","150","","","Percent of Total Billed Charges","neg_dollar:$666.34;150% of Medicaid interim rate","344.80","80","","","Percent of Total Billed Charges","neg_dollar:$344.80;Percent of Total Billed Charges","396.52","92","","","Percent of Total Billed Charges","neg_dollar:$396.52","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","224.00","431.00",""
"BX BREAST 1ST LESION STEREOTACTIC","19081","CPT","10000201","CDM","360","RC","","Facility","Outpatient","","","4644","3715.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","3993.84","86","","","Percent of Total Billed Charges","neg_dollar:$3993.84","3250.79","70","","","Percent of Total Billed Charges","neg_dollar:$3250.79","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","2728.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$2728.34;102% of Medicaid interim rate","3483.00","75","","","Percent of Total Billed Charges","neg_dollar:$3483","3993.84","86","","","Percent of Total Billed Charges","neg_dollar:$3993.84","3250.79","70","","","Percent of Total Billed Charges","neg_dollar:$3250.79","2647.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$2647.08;103.5% of Medicaid interim rate","4644.00","150","","","Percent of Total Billed Charges","neg_dollar:$7179.85;150% of Medicaid interim rate","3715.20","80","","","Percent of Total Billed Charges","neg_dollar:$3715.20;Percent of Total Billed Charges","4272.48","92","","","Percent of Total Billed Charges","neg_dollar:$4272.48","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4644.00",""
"BX BREAST ADD LESION STEREOTACTIC","19082","CPT","10000202","CDM","360","RC","","Facility","Outpatient","","","2555","2044.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","2197.30","86","","","Percent of Total Billed Charges","neg_dollar:$2197.30","1788.50","70","","","Percent of Total Billed Charges","neg_dollar:$1788.50","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","1501.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1501.05;102% of Medicaid interim rate","1916.25","75","","","Percent of Total Billed Charges","neg_dollar:$1916.25","2197.30","86","","","Percent of Total Billed Charges","neg_dollar:$2197.30","1788.50","70","","","Percent of Total Billed Charges","neg_dollar:$1788.50","1456.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$1456.35;103.5% of Medicaid interim rate","2555.00","150","","","Percent of Total Billed Charges","neg_dollar:$3950.15;150% of Medicaid interim rate","2044.00","80","","","Percent of Total Billed Charges","neg_dollar:$2044;Percent of Total Billed Charges","2350.60","92","","","Percent of Total Billed Charges","neg_dollar:$2350.60","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2555.00",""
"BX BREAST 1ST LESION US IMAG","19083","CPT","10000203","CDM","360","RC","","Facility","Outpatient","","","4644","3715.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","3993.84","86","","","Percent of Total Billed Charges","neg_dollar:$3993.84","3250.79","70","","","Percent of Total Billed Charges","neg_dollar:$3250.79","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","2728.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$2728.34;102% of Medicaid interim rate","3483.00","75","","","Percent of Total Billed Charges","neg_dollar:$3483","3993.84","86","","","Percent of Total Billed Charges","neg_dollar:$3993.84","3250.79","70","","","Percent of Total Billed Charges","neg_dollar:$3250.79","2647.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$2647.08;103.5% of Medicaid interim rate","4644.00","150","","","Percent of Total Billed Charges","neg_dollar:$7179.85;150% of Medicaid interim rate","3715.20","80","","","Percent of Total Billed Charges","neg_dollar:$3715.20;Percent of Total Billed Charges","4272.48","92","","","Percent of Total Billed Charges","neg_dollar:$4272.48","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","2414.88","52","","","Percent of Total Billed Charges","neg_dollar:$2414.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4644.00",""
"BX BREAST ADD LESION US IMAG","19084","CPT","10000204","CDM","360","RC","","Facility","Outpatient","","","2555","2044.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","2197.30","86","","","Percent of Total Billed Charges","neg_dollar:$2197.30","1788.50","70","","","Percent of Total Billed Charges","neg_dollar:$1788.50","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","1501.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1501.05;102% of Medicaid interim rate","1916.25","75","","","Percent of Total Billed Charges","neg_dollar:$1916.25","2197.30","86","","","Percent of Total Billed Charges","neg_dollar:$2197.30","1788.50","70","","","Percent of Total Billed Charges","neg_dollar:$1788.50","1456.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$1456.35;103.5% of Medicaid interim rate","2555.00","150","","","Percent of Total Billed Charges","neg_dollar:$3950.15;150% of Medicaid interim rate","2044.00","80","","","Percent of Total Billed Charges","neg_dollar:$2044;Percent of Total Billed Charges","2350.60","92","","","Percent of Total Billed Charges","neg_dollar:$2350.60","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1328.60","52","","","Percent of Total Billed Charges","neg_dollar:$1328.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2555.00",""
"BX BREAST PERC NDL WO GUIDE","19100","CPT","10000108","CDM","360","RC","","Facility","Outpatient","","","1183","946.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","615.16","52","","","Percent of Total Billed Charges","neg_dollar:$615.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","615.16","52","","","Percent of Total Billed Charges","neg_dollar:$615.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","615.16","52","","","Percent of Total Billed Charges","neg_dollar:$615.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","615.16","52","","","Percent of Total Billed Charges","neg_dollar:$615.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1017.38","86","","","Percent of Total Billed Charges","neg_dollar:$1017.38","828.09","70","","","Percent of Total Billed Charges","neg_dollar:$828.09","615.16","52","","","Percent of Total Billed Charges","neg_dollar:$615.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","695.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$695.01;102% of Medicaid interim rate","887.25","75","","","Percent of Total Billed Charges","neg_dollar:$887.25","1017.38","86","","","Percent of Total Billed Charges","neg_dollar:$1017.38","828.09","70","","","Percent of Total Billed Charges","neg_dollar:$828.09","674.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$674.31;103.5% of Medicaid interim rate","1183.00","150","","","Percent of Total Billed Charges","neg_dollar:$1828.97;150% of Medicaid interim rate","946.40","80","","","Percent of Total Billed Charges","neg_dollar:$946.40;Percent of Total Billed Charges","1088.36","92","","","Percent of Total Billed Charges","neg_dollar:$1088.36","615.16","52","","","Percent of Total Billed Charges","neg_dollar:$615.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","615.16","52","","","Percent of Total Billed Charges","neg_dollar:$615.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","615.00","1183.00",""
"PERQ DEV BREAST 1ST LES MAMMO","19281","CPT","10000207","CDM","360","RC","","Facility","Outpatient","","","1578","1262.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","820.56","52","","","Percent of Total Billed Charges","neg_dollar:$820.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","820.56","52","","","Percent of Total Billed Charges","neg_dollar:$820.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","820.56","52","","","Percent of Total Billed Charges","neg_dollar:$820.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","820.56","52","","","Percent of Total Billed Charges","neg_dollar:$820.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1357.08","86","","","Percent of Total Billed Charges","neg_dollar:$1357.08","1104.60","70","","","Percent of Total Billed Charges","neg_dollar:$1104.60","820.56","52","","","Percent of Total Billed Charges","neg_dollar:$820.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","927.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$927.07;102% of Medicaid interim rate","1183.50","75","","","Percent of Total Billed Charges","neg_dollar:$1183.50","1357.08","86","","","Percent of Total Billed Charges","neg_dollar:$1357.08","1104.60","70","","","Percent of Total Billed Charges","neg_dollar:$1104.60","899.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$899.45;103.5% of Medicaid interim rate","1578.00","150","","","Percent of Total Billed Charges","neg_dollar:$2439.66;150% of Medicaid interim rate","1262.40","80","","","Percent of Total Billed Charges","neg_dollar:$1262.40;Percent of Total Billed Charges","1451.76","92","","","Percent of Total Billed Charges","neg_dollar:$1451.76","820.56","52","","","Percent of Total Billed Charges","neg_dollar:$820.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","820.56","52","","","Percent of Total Billed Charges","neg_dollar:$820.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1578.00",""
"PERQ DEV BREAST ADD LES MAMMO","19282","CPT","10000208","CDM","360","RC","","Facility","Outpatient","","","1283","1026.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1103.37","86","","","Percent of Total Billed Charges","neg_dollar:$1103.37","898.09","70","","","Percent of Total Billed Charges","neg_dollar:$898.09","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","753.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$753.76;102% of Medicaid interim rate","962.25","75","","","Percent of Total Billed Charges","neg_dollar:$962.25","1103.37","86","","","Percent of Total Billed Charges","neg_dollar:$1103.37","898.09","70","","","Percent of Total Billed Charges","neg_dollar:$898.09","731.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$731.31;103.5% of Medicaid interim rate","1283.00","150","","","Percent of Total Billed Charges","neg_dollar:$1983.58;150% of Medicaid interim rate","1026.40","80","","","Percent of Total Billed Charges","neg_dollar:$1026.40;Percent of Total Billed Charges","1180.36","92","","","Percent of Total Billed Charges","neg_dollar:$1180.36","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","667.16","52","","","Percent of Total Billed Charges","neg_dollar:$667.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","667.00","1283.00",""
"PERQ DEV BREAST 1ST LES STEREOTACT","19283","CPT","10000209","CDM","360","RC","","Facility","Outpatient","","","1842","1473.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","957.84","52","","","Percent of Total Billed Charges","neg_dollar:$957.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","957.84","52","","","Percent of Total Billed Charges","neg_dollar:$957.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","957.84","52","","","Percent of Total Billed Charges","neg_dollar:$957.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","957.84","52","","","Percent of Total Billed Charges","neg_dollar:$957.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","1584.12","86","","","Percent of Total Billed Charges","neg_dollar:$1584.12","1289.39","70","","","Percent of Total Billed Charges","neg_dollar:$1289.39","957.84","52","","","Percent of Total Billed Charges","neg_dollar:$957.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","1082.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1082.17;102% of Medicaid interim rate","1381.50","75","","","Percent of Total Billed Charges","neg_dollar:$1381.50","1584.12","86","","","Percent of Total Billed Charges","neg_dollar:$1584.12","1289.39","70","","","Percent of Total Billed Charges","neg_dollar:$1289.39","1049.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$1049.93;103.5% of Medicaid interim rate","1842.00","150","","","Percent of Total Billed Charges","neg_dollar:$2847.82;150% of Medicaid interim rate","1473.60","80","","","Percent of Total Billed Charges","neg_dollar:$1473.60;Percent of Total Billed Charges","1694.64","92","","","Percent of Total Billed Charges","neg_dollar:$1694.64","957.84","52","","","Percent of Total Billed Charges","neg_dollar:$957.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","957.84","52","","","Percent of Total Billed Charges","neg_dollar:$957.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1842.00",""
"PERQ DEV BREAST ADD LES STEREOTACT","19284","CPT","10000210","CDM","360","RC","","Facility","Outpatient","","","761","608.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","761.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.46","86","","","Percent of Total Billed Charges","neg_dollar:$654.46","532.69","70","","","Percent of Total Billed Charges","neg_dollar:$532.69","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","447.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$447.08;102% of Medicaid interim rate","570.75","75","","","Percent of Total Billed Charges","neg_dollar:$570.75","654.46","86","","","Percent of Total Billed Charges","neg_dollar:$654.46","532.69","70","","","Percent of Total Billed Charges","neg_dollar:$532.69","433.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$433.77;103.5% of Medicaid interim rate","761.00","150","","","Percent of Total Billed Charges","neg_dollar:$1176.54;150% of Medicaid interim rate","608.80","80","","","Percent of Total Billed Charges","neg_dollar:$608.80;Percent of Total Billed Charges","700.12","92","","","Percent of Total Billed Charges","neg_dollar:$700.12","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","395.00","761.00",""
"PERQ DEV BREAST 1ST LES US IMAG","19285","CPT","10000211","CDM","360","RC","","Facility","Outpatient","","","1536","1228.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1320.96","86","","","Percent of Total Billed Charges","neg_dollar:$1320.96","1075.19","70","","","Percent of Total Billed Charges","neg_dollar:$1075.19","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","902.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$902.39;102% of Medicaid interim rate","1152.00","75","","","Percent of Total Billed Charges","neg_dollar:$1152","1320.96","86","","","Percent of Total Billed Charges","neg_dollar:$1320.96","1075.19","70","","","Percent of Total Billed Charges","neg_dollar:$1075.19","875.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$875.52;103.5% of Medicaid interim rate","1536.00","150","","","Percent of Total Billed Charges","neg_dollar:$2374.73;150% of Medicaid interim rate","1228.80","80","","","Percent of Total Billed Charges","neg_dollar:$1228.80;Percent of Total Billed Charges","1413.12","92","","","Percent of Total Billed Charges","neg_dollar:$1413.12","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1536.00",""
"PERQ DEV BREAST ADD LES US IMAG","19286","CPT","10000212","CDM","360","RC","","Facility","Outpatient","","","761","608.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","761.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.46","86","","","Percent of Total Billed Charges","neg_dollar:$654.46","532.69","70","","","Percent of Total Billed Charges","neg_dollar:$532.69","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","447.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$447.08;102% of Medicaid interim rate","570.75","75","","","Percent of Total Billed Charges","neg_dollar:$570.75","654.46","86","","","Percent of Total Billed Charges","neg_dollar:$654.46","532.69","70","","","Percent of Total Billed Charges","neg_dollar:$532.69","433.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$433.77;103.5% of Medicaid interim rate","761.00","150","","","Percent of Total Billed Charges","neg_dollar:$1176.54;150% of Medicaid interim rate","608.80","80","","","Percent of Total Billed Charges","neg_dollar:$608.80;Percent of Total Billed Charges","700.12","92","","","Percent of Total Billed Charges","neg_dollar:$700.12","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","395.72","52","","","Percent of Total Billed Charges","neg_dollar:$395.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","395.00","761.00",""
"INJ SINUS TRACT DIAGNOSTIC","20501","CPT","20000176","CDM","360","RC","","Facility","Outpatient","","","387","309.60","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","227.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$227.36;102% of Medicaid interim rate","290.25","75","","","Percent of Total Billed Charges","neg_dollar:$290.25","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","220.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$220.58;103.5% of Medicaid interim rate","387.00","150","","","Percent of Total Billed Charges","neg_dollar:$598.32;150% of Medicaid interim rate","309.60","80","","","Percent of Total Billed Charges","neg_dollar:$309.60;Percent of Total Billed Charges","356.04","92","","","Percent of Total Billed Charges","neg_dollar:$356.04","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.00","387.00",""
"INJ SGL TENDON SHTH OR LIGAMENT","20550","CPT","20000110","CDM","761","RC","","Facility","Outpatient","","","846","676.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","727.56","86","","","Percent of Total Billed Charges","neg_dollar:$727.56","592.19","70","","","Percent of Total Billed Charges","neg_dollar:$592.19","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","497.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$497.02;102% of Medicaid interim rate","634.50","75","","","Percent of Total Billed Charges","neg_dollar:$634.50","727.56","86","","","Percent of Total Billed Charges","neg_dollar:$727.56","592.19","70","","","Percent of Total Billed Charges","neg_dollar:$592.19","482.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$482.21;103.5% of Medicaid interim rate","846.00","150","","","Percent of Total Billed Charges","neg_dollar:$1307.95;150% of Medicaid interim rate","676.80","80","","","Percent of Total Billed Charges","neg_dollar:$676.80;Percent of Total Billed Charges","778.32","92","","","Percent of Total Billed Charges","neg_dollar:$778.32","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","439.00","846.00",""
"INJ TRIGGER POINT 1/2 MUSCL","20552","CPT","20000111","CDM","761","RC","","Facility","Outpatient","","","847","677.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","497.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$497.61;102% of Medicaid interim rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","482.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$482.78;103.5% of Medicaid interim rate","847.00","150","","","Percent of Total Billed Charges","neg_dollar:$1309.50;150% of Medicaid interim rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","779.24","92","","","Percent of Total Billed Charges","neg_dollar:$779.24","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.00","847.00",""
"INJECT TRIGGER POINTS=/>3","20553","CPT","20000004","CDM","761","RC","","Facility","Outpatient","","","847","677.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","497.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$497.61;102% of Medicaid interim rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","482.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$482.78;103.5% of Medicaid interim rate","847.00","150","","","Percent of Total Billed Charges","neg_dollar:$1309.50;150% of Medicaid interim rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","779.24","92","","","Percent of Total Billed Charges","neg_dollar:$779.24","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.00","847.00",""
"NDL INSJ W/O NJX 1 OR 2 MUSC","20560","CPT","20000590","CDM","761","RC","","Facility","Outpatient","","","50","40.00","50.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;101% Medicare Outpatient Cost to Charge Ratio of 52%","50.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;102% Medicare Outpatient Cost to Charge Ratio of 52%","43.00","86","","","Percent of Total Billed Charges","neg_dollar:$43","35.00","70","","","Percent of Total Billed Charges","neg_dollar:$35","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;105% Medicare Outpatient Cost to Charge Ratio of 52%","29.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.37;102% of Medicaid interim rate","37.50","75","","","Percent of Total Billed Charges","neg_dollar:$37.50","43.00","86","","","Percent of Total Billed Charges","neg_dollar:$43","35.00","70","","","Percent of Total Billed Charges","neg_dollar:$35","28.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.49;103.5% of Medicaid interim rate","50.00","150","","","Percent of Total Billed Charges","neg_dollar:$77.30;150% of Medicaid interim rate","40.00","80","","","Percent of Total Billed Charges","neg_dollar:$40;Percent of Total Billed Charges","46.00","92","","","Percent of Total Billed Charges","neg_dollar:$46","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;100% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;100% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","50.00",""
"NDL INSJ W/O NJX 3+ MUSC","20561","CPT","20000591","CDM","761","RC","","Facility","Outpatient","","","72","57.60","72.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","37.44","52","","","Percent of Total Billed Charges","neg_dollar:$37.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","72.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","37.44","52","","","Percent of Total Billed Charges","neg_dollar:$37.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","37.44","52","","","Percent of Total Billed Charges","neg_dollar:$37.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","37.44","52","","","Percent of Total Billed Charges","neg_dollar:$37.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","61.92","86","","","Percent of Total Billed Charges","neg_dollar:$61.92","50.40","70","","","Percent of Total Billed Charges","neg_dollar:$50.40","37.44","52","","","Percent of Total Billed Charges","neg_dollar:$37.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","42.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$42.29;102% of Medicaid interim rate","54.00","75","","","Percent of Total Billed Charges","neg_dollar:$54","61.92","86","","","Percent of Total Billed Charges","neg_dollar:$61.92","50.40","70","","","Percent of Total Billed Charges","neg_dollar:$50.40","41.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$41.04;103.5% of Medicaid interim rate","72.00","150","","","Percent of Total Billed Charges","neg_dollar:$111.31;150% of Medicaid interim rate","57.60","80","","","Percent of Total Billed Charges","neg_dollar:$57.60;Percent of Total Billed Charges","66.24","92","","","Percent of Total Billed Charges","neg_dollar:$66.24","37.44","52","","","Percent of Total Billed Charges","neg_dollar:$37.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","37.44","52","","","Percent of Total Billed Charges","neg_dollar:$37.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","37.00","72.00",""
"DRAIN/INJ JOINT/BURSA W/O US","20600","CPT","20000112","CDM","360","RC","","Facility","Outpatient","","","847","677.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","497.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$497.61;102% of Medicaid interim rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","482.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$482.78;103.5% of Medicaid interim rate","847.00","150","","","Percent of Total Billed Charges","neg_dollar:$1309.50;150% of Medicaid interim rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","779.24","92","","","Percent of Total Billed Charges","neg_dollar:$779.24","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.00","847.00",""
"DRAIN/INJ SMALL JOINT/BURSA W US","20604","CPT","20000355","CDM","761","RC","","Facility","Outpatient","","","750","600.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;101% Medicare Outpatient Cost to Charge Ratio of 52%","750.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;102% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;102% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;102% Medicare Outpatient Cost to Charge Ratio of 52%","645.00","86","","","Percent of Total Billed Charges","neg_dollar:$645","525.00","70","","","Percent of Total Billed Charges","neg_dollar:$525","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;105% Medicare Outpatient Cost to Charge Ratio of 52%","440.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$440.62;102% of Medicaid interim rate","562.50","75","","","Percent of Total Billed Charges","neg_dollar:$562.50","645.00","86","","","Percent of Total Billed Charges","neg_dollar:$645","525.00","70","","","Percent of Total Billed Charges","neg_dollar:$525","427.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$427.49;103.5% of Medicaid interim rate","750.00","150","","","Percent of Total Billed Charges","neg_dollar:$1159.53;150% of Medicaid interim rate","600.00","80","","","Percent of Total Billed Charges","neg_dollar:$600;Percent of Total Billed Charges","690.00","92","","","Percent of Total Billed Charges","neg_dollar:$690","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;100% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;100% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","750.00",""
"DRAIN/INJ INTERM JNT/BURSA","20605","CPT","20000113","CDM","761","RC","","Facility","Outpatient","","","847","677.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","497.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$497.61;102% of Medicaid interim rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","482.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$482.78;103.5% of Medicaid interim rate","847.00","150","","","Percent of Total Billed Charges","neg_dollar:$1309.50;150% of Medicaid interim rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","779.24","92","","","Percent of Total Billed Charges","neg_dollar:$779.24","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.00","847.00",""
"DRAIN/INJ INTERM JNT/BURSA BILAT","20605","CPT","20000114","CDM","761","RC","50","Facility","Outpatient","","","1269","1015.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1091.34","86","","","Percent of Total Billed Charges","neg_dollar:$1091.34","888.30","70","","","Percent of Total Billed Charges","neg_dollar:$888.30","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","745.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$745.53;102% of Medicaid interim rate","951.75","75","","","Percent of Total Billed Charges","neg_dollar:$951.75","1091.34","86","","","Percent of Total Billed Charges","neg_dollar:$1091.34","888.30","70","","","Percent of Total Billed Charges","neg_dollar:$888.30","723.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$723.32;103.5% of Medicaid interim rate","1269.00","150","","","Percent of Total Billed Charges","neg_dollar:$1961.93;150% of Medicaid interim rate","1015.20","80","","","Percent of Total Billed Charges","neg_dollar:$1015.20;Percent of Total Billed Charges","1167.48","92","","","Percent of Total Billed Charges","neg_dollar:$1167.48","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","659.00","1269.00",""
"DRAIN/INJ INTERM JOINT/BURSA W US","20606","CPT","20000356","CDM","761","RC","","Facility","Outpatient","","","856","684.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","445.12","52","","","Percent of Total Billed Charges","neg_dollar:$445.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","445.12","52","","","Percent of Total Billed Charges","neg_dollar:$445.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","445.12","52","","","Percent of Total Billed Charges","neg_dollar:$445.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","445.12","52","","","Percent of Total Billed Charges","neg_dollar:$445.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","736.16","86","","","Percent of Total Billed Charges","neg_dollar:$736.16","599.19","70","","","Percent of Total Billed Charges","neg_dollar:$599.19","445.12","52","","","Percent of Total Billed Charges","neg_dollar:$445.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","502.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$502.89;102% of Medicaid interim rate","642.00","75","","","Percent of Total Billed Charges","neg_dollar:$642","736.16","86","","","Percent of Total Billed Charges","neg_dollar:$736.16","599.19","70","","","Percent of Total Billed Charges","neg_dollar:$599.19","487.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$487.91;103.5% of Medicaid interim rate","856.00","150","","","Percent of Total Billed Charges","neg_dollar:$1323.41;150% of Medicaid interim rate","684.80","80","","","Percent of Total Billed Charges","neg_dollar:$684.80;Percent of Total Billed Charges","787.52","92","","","Percent of Total Billed Charges","neg_dollar:$787.52","445.12","52","","","Percent of Total Billed Charges","neg_dollar:$445.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","445.12","52","","","Percent of Total Billed Charges","neg_dollar:$445.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","445.00","856.00",""
"DRAIN/INJ MAJOR JNT/BURSA","20610","CPT","20000115","CDM","761","RC","","Facility","Outpatient","","","847","677.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","497.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$497.61;102% of Medicaid interim rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","482.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$482.78;103.5% of Medicaid interim rate","847.00","150","","","Percent of Total Billed Charges","neg_dollar:$1309.50;150% of Medicaid interim rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","779.24","92","","","Percent of Total Billed Charges","neg_dollar:$779.24","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.00","847.00",""
"DRAIN/INJ MAJOR JNT/BURSA BILAT","20610","CPT","20000116","CDM","761","RC","50","Facility","Outpatient","","","1269","1015.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1091.34","86","","","Percent of Total Billed Charges","neg_dollar:$1091.34","888.30","70","","","Percent of Total Billed Charges","neg_dollar:$888.30","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","745.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$745.53;102% of Medicaid interim rate","951.75","75","","","Percent of Total Billed Charges","neg_dollar:$951.75","1091.34","86","","","Percent of Total Billed Charges","neg_dollar:$1091.34","888.30","70","","","Percent of Total Billed Charges","neg_dollar:$888.30","723.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$723.32;103.5% of Medicaid interim rate","1269.00","150","","","Percent of Total Billed Charges","neg_dollar:$1961.93;150% of Medicaid interim rate","1015.20","80","","","Percent of Total Billed Charges","neg_dollar:$1015.20;Percent of Total Billed Charges","1167.48","92","","","Percent of Total Billed Charges","neg_dollar:$1167.48","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","659.88","52","","","Percent of Total Billed Charges","neg_dollar:$659.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","659.00","1269.00",""
"DRAIN/INJ MAJOR JOINT/BURSA W US","20611","CPT","20000357","CDM","761","RC","","Facility","Outpatient","","","469","375.20","469.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","243.88","52","","","Percent of Total Billed Charges","neg_dollar:$243.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","469.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","243.88","52","","","Percent of Total Billed Charges","neg_dollar:$243.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","243.88","52","","","Percent of Total Billed Charges","neg_dollar:$243.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","243.88","52","","","Percent of Total Billed Charges","neg_dollar:$243.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","403.34","86","","","Percent of Total Billed Charges","neg_dollar:$403.34","328.29","70","","","Percent of Total Billed Charges","neg_dollar:$328.29","243.88","52","","","Percent of Total Billed Charges","neg_dollar:$243.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","275.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$275.53;102% of Medicaid interim rate","351.75","75","","","Percent of Total Billed Charges","neg_dollar:$351.75","403.34","86","","","Percent of Total Billed Charges","neg_dollar:$403.34","328.29","70","","","Percent of Total Billed Charges","neg_dollar:$328.29","267.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$267.33;103.5% of Medicaid interim rate","469.00","150","","","Percent of Total Billed Charges","neg_dollar:$725.09;150% of Medicaid interim rate","375.20","80","","","Percent of Total Billed Charges","neg_dollar:$375.20;Percent of Total Billed Charges","431.48","92","","","Percent of Total Billed Charges","neg_dollar:$431.48","243.88","52","","","Percent of Total Billed Charges","neg_dollar:$243.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","243.88","52","","","Percent of Total Billed Charges","neg_dollar:$243.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","243.00","469.00",""
"DRAIN/INJ MAJOR JOINT/BURSA W/US BILAT","20611","CPT","20000445","CDM","761","RC","50","Facility","Outpatient","","","705","564.00","705.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","705.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","606.30","86","","","Percent of Total Billed Charges","neg_dollar:$606.30","493.49","70","","","Percent of Total Billed Charges","neg_dollar:$493.49","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","414.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$414.18;102% of Medicaid interim rate","528.75","75","","","Percent of Total Billed Charges","neg_dollar:$528.75","606.30","86","","","Percent of Total Billed Charges","neg_dollar:$606.30","493.49","70","","","Percent of Total Billed Charges","neg_dollar:$493.49","401.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$401.84;103.5% of Medicaid interim rate","705.00","150","","","Percent of Total Billed Charges","neg_dollar:$1089.96;150% of Medicaid interim rate","564.00","80","","","Percent of Total Billed Charges","neg_dollar:$564;Percent of Total Billed Charges","648.60","92","","","Percent of Total Billed Charges","neg_dollar:$648.60","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.00","705.00",""
"CL TX TMJ DISLOCATION INITIAL","21480","CPT","20000006","CDM","450","RC","","Facility","Outpatient","","","753","602.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","391.56","52","","","Percent of Total Billed Charges","neg_dollar:$391.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","753.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","391.56","52","","","Percent of Total Billed Charges","neg_dollar:$391.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","391.56","52","","","Percent of Total Billed Charges","neg_dollar:$391.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","391.56","52","","","Percent of Total Billed Charges","neg_dollar:$391.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","647.58","86","","","Percent of Total Billed Charges","neg_dollar:$647.58","527.10","70","","","Percent of Total Billed Charges","neg_dollar:$527.10","391.56","52","","","Percent of Total Billed Charges","neg_dollar:$391.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","442.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$442.38;102% of Medicaid interim rate","564.75","75","","","Percent of Total Billed Charges","neg_dollar:$564.75","647.58","86","","","Percent of Total Billed Charges","neg_dollar:$647.58","527.10","70","","","Percent of Total Billed Charges","neg_dollar:$527.10","429.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$429.21;103.5% of Medicaid interim rate","753.00","150","","","Percent of Total Billed Charges","neg_dollar:$1164.17;150% of Medicaid interim rate","602.40","80","","","Percent of Total Billed Charges","neg_dollar:$602.40;Percent of Total Billed Charges","692.76","92","","","Percent of Total Billed Charges","neg_dollar:$692.76","391.56","52","","","Percent of Total Billed Charges","neg_dollar:$391.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","391.56","52","","","Percent of Total Billed Charges","neg_dollar:$391.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","391.00","753.00",""
"INJ ARTHROGRAM SHOULDER","23350","CPT","20000187","CDM","360","RC","","Facility","Outpatient","","","261","208.80","261.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","135.72","52","","","Percent of Total Billed Charges","neg_dollar:$135.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","261.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","135.72","52","","","Percent of Total Billed Charges","neg_dollar:$135.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","135.72","52","","","Percent of Total Billed Charges","neg_dollar:$135.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","135.72","52","","","Percent of Total Billed Charges","neg_dollar:$135.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","224.46","86","","","Percent of Total Billed Charges","neg_dollar:$224.46","182.70","70","","","Percent of Total Billed Charges","neg_dollar:$182.70","135.72","52","","","Percent of Total Billed Charges","neg_dollar:$135.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","153.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$153.33;102% of Medicaid interim rate","195.75","75","","","Percent of Total Billed Charges","neg_dollar:$195.75","224.46","86","","","Percent of Total Billed Charges","neg_dollar:$224.46","182.70","70","","","Percent of Total Billed Charges","neg_dollar:$182.70","148.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$148.76;103.5% of Medicaid interim rate","261.00","150","","","Percent of Total Billed Charges","neg_dollar:$403.51;150% of Medicaid interim rate","208.80","80","","","Percent of Total Billed Charges","neg_dollar:$208.80;Percent of Total Billed Charges","240.12","92","","","Percent of Total Billed Charges","neg_dollar:$240.12","135.72","52","","","Percent of Total Billed Charges","neg_dollar:$135.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","135.72","52","","","Percent of Total Billed Charges","neg_dollar:$135.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","135.00","261.00",""
"CL TX ACLAV DISLOC W MANIP","23545","CPT","20000132","CDM","450","RC","","Facility","Outpatient","","","1284","1027.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","667.68","52","","","Percent of Total Billed Charges","neg_dollar:$667.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","667.68","52","","","Percent of Total Billed Charges","neg_dollar:$667.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","667.68","52","","","Percent of Total Billed Charges","neg_dollar:$667.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","667.68","52","","","Percent of Total Billed Charges","neg_dollar:$667.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1104.24","86","","","Percent of Total Billed Charges","neg_dollar:$1104.24","898.80","70","","","Percent of Total Billed Charges","neg_dollar:$898.80","667.68","52","","","Percent of Total Billed Charges","neg_dollar:$667.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","754.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$754.34;102% of Medicaid interim rate","963.00","75","","","Percent of Total Billed Charges","neg_dollar:$963","1104.24","86","","","Percent of Total Billed Charges","neg_dollar:$1104.24","898.80","70","","","Percent of Total Billed Charges","neg_dollar:$898.80","731.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$731.87;103.5% of Medicaid interim rate","1284.00","150","","","Percent of Total Billed Charges","neg_dollar:$1985.12;150% of Medicaid interim rate","1027.20","80","","","Percent of Total Billed Charges","neg_dollar:$1027.20;Percent of Total Billed Charges","1181.28","92","","","Percent of Total Billed Charges","neg_dollar:$1181.28","667.68","52","","","Percent of Total Billed Charges","neg_dollar:$667.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","667.68","52","","","Percent of Total Billed Charges","neg_dollar:$667.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","667.00","1284.00",""
"CL TX SCAPULAR FX W MANIP","23575","CPT","20000318","CDM","450","RC","","Facility","Outpatient","","","1166","932.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","606.32","52","","","Percent of Total Billed Charges","neg_dollar:$606.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","606.32","52","","","Percent of Total Billed Charges","neg_dollar:$606.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","606.32","52","","","Percent of Total Billed Charges","neg_dollar:$606.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","606.32","52","","","Percent of Total Billed Charges","neg_dollar:$606.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1002.76","86","","","Percent of Total Billed Charges","neg_dollar:$1002.76","816.19","70","","","Percent of Total Billed Charges","neg_dollar:$816.19","606.32","52","","","Percent of Total Billed Charges","neg_dollar:$606.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","685.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$685.02;102% of Medicaid interim rate","874.50","75","","","Percent of Total Billed Charges","neg_dollar:$874.50","1002.76","86","","","Percent of Total Billed Charges","neg_dollar:$1002.76","816.19","70","","","Percent of Total Billed Charges","neg_dollar:$816.19","664.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$664.61;103.5% of Medicaid interim rate","1166.00","150","","","Percent of Total Billed Charges","neg_dollar:$1802.69;150% of Medicaid interim rate","932.80","80","","","Percent of Total Billed Charges","neg_dollar:$932.80;Percent of Total Billed Charges","1072.72","92","","","Percent of Total Billed Charges","neg_dollar:$1072.72","606.32","52","","","Percent of Total Billed Charges","neg_dollar:$606.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","606.32","52","","","Percent of Total Billed Charges","neg_dollar:$606.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","606.00","1166.00",""
"CL TX SHLDR DISL W MANI WO ANESTH","23650","CPT","20000016","CDM","450","RC","","Facility","Outpatient","","","674","539.20","674.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","350.48","52","","","Percent of Total Billed Charges","neg_dollar:$350.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","674.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","350.48","52","","","Percent of Total Billed Charges","neg_dollar:$350.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","350.48","52","","","Percent of Total Billed Charges","neg_dollar:$350.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","350.48","52","","","Percent of Total Billed Charges","neg_dollar:$350.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","579.64","86","","","Percent of Total Billed Charges","neg_dollar:$579.64","471.79","70","","","Percent of Total Billed Charges","neg_dollar:$471.79","350.48","52","","","Percent of Total Billed Charges","neg_dollar:$350.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","395.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$395.97;102% of Medicaid interim rate","505.50","75","","","Percent of Total Billed Charges","neg_dollar:$505.50","579.64","86","","","Percent of Total Billed Charges","neg_dollar:$579.64","471.79","70","","","Percent of Total Billed Charges","neg_dollar:$471.79","384.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$384.17;103.5% of Medicaid interim rate","674.00","150","","","Percent of Total Billed Charges","neg_dollar:$1042.03;150% of Medicaid interim rate","539.20","80","","","Percent of Total Billed Charges","neg_dollar:$539.20;Percent of Total Billed Charges","620.08","92","","","Percent of Total Billed Charges","neg_dollar:$620.08","350.48","52","","","Percent of Total Billed Charges","neg_dollar:$350.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","350.48","52","","","Percent of Total Billed Charges","neg_dollar:$350.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","350.00","674.00",""
"CL TX SHLDR DISL W MANIP W ANESTH","23655","CPT","20000134","CDM","450","RC","","Facility","Outpatient","","","2113","1690.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1098.76","52","","","Percent of Total Billed Charges","neg_dollar:$1098.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1098.76","52","","","Percent of Total Billed Charges","neg_dollar:$1098.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1098.76","52","","","Percent of Total Billed Charges","neg_dollar:$1098.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1098.76","52","","","Percent of Total Billed Charges","neg_dollar:$1098.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1817.18","86","","","Percent of Total Billed Charges","neg_dollar:$1817.18","1479.10","70","","","Percent of Total Billed Charges","neg_dollar:$1479.10","1098.76","52","","","Percent of Total Billed Charges","neg_dollar:$1098.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","1241.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$1241.38;102% of Medicaid interim rate","1584.75","75","","","Percent of Total Billed Charges","neg_dollar:$1584.75","1817.18","86","","","Percent of Total Billed Charges","neg_dollar:$1817.18","1479.10","70","","","Percent of Total Billed Charges","neg_dollar:$1479.10","1204.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$1204.40;103.5% of Medicaid interim rate","2113.00","150","","","Percent of Total Billed Charges","neg_dollar:$3266.80;150% of Medicaid interim rate","1690.40","80","","","Percent of Total Billed Charges","neg_dollar:$1690.40;Percent of Total Billed Charges","1943.96","92","","","Percent of Total Billed Charges","neg_dollar:$1943.96","1098.76","52","","","Percent of Total Billed Charges","neg_dollar:$1098.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1098.76","52","","","Percent of Total Billed Charges","neg_dollar:$1098.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2113.00",""
"CL TX SHLDR DISLOC & FX GT W MANIP","23665","CPT","20000017","CDM","450","RC","","Facility","Outpatient","","","1391","1112.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","723.32","52","","","Percent of Total Billed Charges","neg_dollar:$723.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","723.32","52","","","Percent of Total Billed Charges","neg_dollar:$723.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","723.32","52","","","Percent of Total Billed Charges","neg_dollar:$723.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","723.32","52","","","Percent of Total Billed Charges","neg_dollar:$723.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.26","86","","","Percent of Total Billed Charges","neg_dollar:$1196.26","973.69","70","","","Percent of Total Billed Charges","neg_dollar:$973.69","723.32","52","","","Percent of Total Billed Charges","neg_dollar:$723.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","817.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$817.21;102% of Medicaid interim rate","1043.25","75","","","Percent of Total Billed Charges","neg_dollar:$1043.25","1196.26","86","","","Percent of Total Billed Charges","neg_dollar:$1196.26","973.69","70","","","Percent of Total Billed Charges","neg_dollar:$973.69","792.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$792.86;103.5% of Medicaid interim rate","1391.00","150","","","Percent of Total Billed Charges","neg_dollar:$2150.55;150% of Medicaid interim rate","1112.80","80","","","Percent of Total Billed Charges","neg_dollar:$1112.80;Percent of Total Billed Charges","1279.72","92","","","Percent of Total Billed Charges","neg_dollar:$1279.72","723.32","52","","","Percent of Total Billed Charges","neg_dollar:$723.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","723.32","52","","","Percent of Total Billed Charges","neg_dollar:$723.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","723.00","1391.00",""
"I&D BURSA UA/ELBOW","23931","CPT","20000226","CDM","360","RC","","Facility","Outpatient","","","1405","1124.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","730.60","52","","","Percent of Total Billed Charges","neg_dollar:$730.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","730.60","52","","","Percent of Total Billed Charges","neg_dollar:$730.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","730.60","52","","","Percent of Total Billed Charges","neg_dollar:$730.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","730.60","52","","","Percent of Total Billed Charges","neg_dollar:$730.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","1208.30","86","","","Percent of Total Billed Charges","neg_dollar:$1208.30","983.49","70","","","Percent of Total Billed Charges","neg_dollar:$983.49","730.60","52","","","Percent of Total Billed Charges","neg_dollar:$730.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","825.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$825.43;102% of Medicaid interim rate","1053.75","75","","","Percent of Total Billed Charges","neg_dollar:$1053.75","1208.30","86","","","Percent of Total Billed Charges","neg_dollar:$1208.30","983.49","70","","","Percent of Total Billed Charges","neg_dollar:$983.49","800.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$800.84;103.5% of Medicaid interim rate","1405.00","150","","","Percent of Total Billed Charges","neg_dollar:$2172.20;150% of Medicaid interim rate","1124.00","80","","","Percent of Total Billed Charges","neg_dollar:$1124;Percent of Total Billed Charges","1292.60","92","","","Percent of Total Billed Charges","neg_dollar:$1292.60","730.60","52","","","Percent of Total Billed Charges","neg_dollar:$730.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","730.60","52","","","Percent of Total Billed Charges","neg_dollar:$730.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","730.00","1405.00",""
"TX CL ELBOW DISLOC WO ANESTH","24600","CPT","20000021","CDM","450","RC","","Facility","Outpatient","","","681","544.80","681.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","354.12","52","","","Percent of Total Billed Charges","neg_dollar:$354.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","681.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","354.12","52","","","Percent of Total Billed Charges","neg_dollar:$354.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","354.12","52","","","Percent of Total Billed Charges","neg_dollar:$354.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","354.12","52","","","Percent of Total Billed Charges","neg_dollar:$354.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","585.66","86","","","Percent of Total Billed Charges","neg_dollar:$585.66","476.70","70","","","Percent of Total Billed Charges","neg_dollar:$476.70","354.12","52","","","Percent of Total Billed Charges","neg_dollar:$354.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","400.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$400.08;102% of Medicaid interim rate","510.75","75","","","Percent of Total Billed Charges","neg_dollar:$510.75","585.66","86","","","Percent of Total Billed Charges","neg_dollar:$585.66","476.70","70","","","Percent of Total Billed Charges","neg_dollar:$476.70","388.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$388.16;103.5% of Medicaid interim rate","681.00","150","","","Percent of Total Billed Charges","neg_dollar:$1052.86;150% of Medicaid interim rate","544.80","80","","","Percent of Total Billed Charges","neg_dollar:$544.80;Percent of Total Billed Charges","626.52","92","","","Percent of Total Billed Charges","neg_dollar:$626.52","354.12","52","","","Percent of Total Billed Charges","neg_dollar:$354.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","354.12","52","","","Percent of Total Billed Charges","neg_dollar:$354.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","354.00","681.00",""
"TX CL ELBOW DISLOC W ANESTH","24605","CPT","20000195","CDM","450","RC","","Facility","Outpatient","","","1055","844.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","907.30","86","","","Percent of Total Billed Charges","neg_dollar:$907.30","738.50","70","","","Percent of Total Billed Charges","neg_dollar:$738.50","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","619.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$619.81;102% of Medicaid interim rate","791.25","75","","","Percent of Total Billed Charges","neg_dollar:$791.25","907.30","86","","","Percent of Total Billed Charges","neg_dollar:$907.30","738.50","70","","","Percent of Total Billed Charges","neg_dollar:$738.50","601.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$601.34;103.5% of Medicaid interim rate","1055.00","150","","","Percent of Total Billed Charges","neg_dollar:$1631.08;150% of Medicaid interim rate","844.00","80","","","Percent of Total Billed Charges","neg_dollar:$844;Percent of Total Billed Charges","970.60","92","","","Percent of Total Billed Charges","neg_dollar:$970.60","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","548.00","1055.00",""
"CL TX NURSEMAID ELBOW W MANIP","24640","CPT","20000022","CDM","450","RC","","Facility","Outpatient","","","518","414.40","518.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","269.36","52","","","Percent of Total Billed Charges","neg_dollar:$269.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","518.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","269.36","52","","","Percent of Total Billed Charges","neg_dollar:$269.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","269.36","52","","","Percent of Total Billed Charges","neg_dollar:$269.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","269.36","52","","","Percent of Total Billed Charges","neg_dollar:$269.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","445.48","86","","","Percent of Total Billed Charges","neg_dollar:$445.48","362.59","70","","","Percent of Total Billed Charges","neg_dollar:$362.59","269.36","52","","","Percent of Total Billed Charges","neg_dollar:$269.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","304.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$304.32;102% of Medicaid interim rate","388.50","75","","","Percent of Total Billed Charges","neg_dollar:$388.50","445.48","86","","","Percent of Total Billed Charges","neg_dollar:$445.48","362.59","70","","","Percent of Total Billed Charges","neg_dollar:$362.59","295.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$295.26;103.5% of Medicaid interim rate","518.00","150","","","Percent of Total Billed Charges","neg_dollar:$800.85;150% of Medicaid interim rate","414.40","80","","","Percent of Total Billed Charges","neg_dollar:$414.40;Percent of Total Billed Charges","476.56","92","","","Percent of Total Billed Charges","neg_dollar:$476.56","269.36","52","","","Percent of Total Billed Charges","neg_dollar:$269.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","269.36","52","","","Percent of Total Billed Charges","neg_dollar:$269.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","269.00","518.00",""
"INCISION OF TENDON SHEATH","25000","CPT","20000604","CDM","360","RC","","Facility","Outpatient","","","1712","1369.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","890.24","52","","","Percent of Total Billed Charges","neg_dollar:$890.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","890.24","52","","","Percent of Total Billed Charges","neg_dollar:$890.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","890.24","52","","","Percent of Total Billed Charges","neg_dollar:$890.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","890.24","52","","","Percent of Total Billed Charges","neg_dollar:$890.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1472.32","86","","","Percent of Total Billed Charges","neg_dollar:$1472.32","1198.39","70","","","Percent of Total Billed Charges","neg_dollar:$1198.39","890.24","52","","","Percent of Total Billed Charges","neg_dollar:$890.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","1005.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$1005.79;102% of Medicaid interim rate","1284.00","75","","","Percent of Total Billed Charges","neg_dollar:$1284","1472.32","86","","","Percent of Total Billed Charges","neg_dollar:$1472.32","1198.39","70","","","Percent of Total Billed Charges","neg_dollar:$1198.39","975.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$975.83;103.5% of Medicaid interim rate","1712.00","150","","","Percent of Total Billed Charges","neg_dollar:$2646.83;150% of Medicaid interim rate","1369.60","80","","","Percent of Total Billed Charges","neg_dollar:$1369.60;Percent of Total Billed Charges","1575.04","92","","","Percent of Total Billed Charges","neg_dollar:$1575.04","890.24","52","","","Percent of Total Billed Charges","neg_dollar:$890.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","890.24","52","","","Percent of Total Billed Charges","neg_dollar:$890.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1712.00",""
"TX FRACTURE D RADIUS/ULNA W MANIP","25605","CPT","20000033","CDM","450","RC","","Facility","Outpatient","","","917","733.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","476.84","52","","","Percent of Total Billed Charges","neg_dollar:$476.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","476.84","52","","","Percent of Total Billed Charges","neg_dollar:$476.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","476.84","52","","","Percent of Total Billed Charges","neg_dollar:$476.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","476.84","52","","","Percent of Total Billed Charges","neg_dollar:$476.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","788.62","86","","","Percent of Total Billed Charges","neg_dollar:$788.62","641.90","70","","","Percent of Total Billed Charges","neg_dollar:$641.90","476.84","52","","","Percent of Total Billed Charges","neg_dollar:$476.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","538.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$538.73;102% of Medicaid interim rate","687.75","75","","","Percent of Total Billed Charges","neg_dollar:$687.75","788.62","86","","","Percent of Total Billed Charges","neg_dollar:$788.62","641.90","70","","","Percent of Total Billed Charges","neg_dollar:$641.90","522.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$522.68;103.5% of Medicaid interim rate","917.00","150","","","Percent of Total Billed Charges","neg_dollar:$1417.72;150% of Medicaid interim rate","733.60","80","","","Percent of Total Billed Charges","neg_dollar:$733.60;Percent of Total Billed Charges","843.64","92","","","Percent of Total Billed Charges","neg_dollar:$843.64","476.84","52","","","Percent of Total Billed Charges","neg_dollar:$476.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","476.84","52","","","Percent of Total Billed Charges","neg_dollar:$476.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","476.00","917.00",""
"TX FX DISTAL RADIAL/EPIPHYS SEPARATION","25606","CPT","20000306","CDM","450","RC","","Facility","Outpatient","","","1894","1515.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","984.88","52","","","Percent of Total Billed Charges","neg_dollar:$984.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","984.88","52","","","Percent of Total Billed Charges","neg_dollar:$984.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","984.88","52","","","Percent of Total Billed Charges","neg_dollar:$984.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","984.88","52","","","Percent of Total Billed Charges","neg_dollar:$984.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1628.84","86","","","Percent of Total Billed Charges","neg_dollar:$1628.84","1325.80","70","","","Percent of Total Billed Charges","neg_dollar:$1325.80","984.88","52","","","Percent of Total Billed Charges","neg_dollar:$984.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","1112.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$1112.72;102% of Medicaid interim rate","1420.50","75","","","Percent of Total Billed Charges","neg_dollar:$1420.50","1628.84","86","","","Percent of Total Billed Charges","neg_dollar:$1628.84","1325.80","70","","","Percent of Total Billed Charges","neg_dollar:$1325.80","1079.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$1079.58;103.5% of Medicaid interim rate","1894.00","150","","","Percent of Total Billed Charges","neg_dollar:$2928.21;150% of Medicaid interim rate","1515.20","80","","","Percent of Total Billed Charges","neg_dollar:$1515.20;Percent of Total Billed Charges","1742.48","92","","","Percent of Total Billed Charges","neg_dollar:$1742.48","984.88","52","","","Percent of Total Billed Charges","neg_dollar:$984.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","984.88","52","","","Percent of Total Billed Charges","neg_dollar:$984.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1894.00",""
"TENDON SHEATH INCISION","26055","CPT","20000381","CDM","360","RC","","Facility","Outpatient","","","1759","1407.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","914.68","52","","","Percent of Total Billed Charges","neg_dollar:$914.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","914.68","52","","","Percent of Total Billed Charges","neg_dollar:$914.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","914.68","52","","","Percent of Total Billed Charges","neg_dollar:$914.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","914.68","52","","","Percent of Total Billed Charges","neg_dollar:$914.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1512.74","86","","","Percent of Total Billed Charges","neg_dollar:$1512.74","1231.30","70","","","Percent of Total Billed Charges","neg_dollar:$1231.30","914.68","52","","","Percent of Total Billed Charges","neg_dollar:$914.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","1033.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$1033.41;102% of Medicaid interim rate","1319.25","75","","","Percent of Total Billed Charges","neg_dollar:$1319.25","1512.74","86","","","Percent of Total Billed Charges","neg_dollar:$1512.74","1231.30","70","","","Percent of Total Billed Charges","neg_dollar:$1231.30","1002.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$1002.62;103.5% of Medicaid interim rate","1759.00","150","","","Percent of Total Billed Charges","neg_dollar:$2719.50;150% of Medicaid interim rate","1407.20","80","","","Percent of Total Billed Charges","neg_dollar:$1407.20;Percent of Total Billed Charges","1618.28","92","","","Percent of Total Billed Charges","neg_dollar:$1618.28","914.68","52","","","Percent of Total Billed Charges","neg_dollar:$914.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","914.68","52","","","Percent of Total Billed Charges","neg_dollar:$914.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1759.00",""
"PALM W SGL DIGIT RELEASE","26123","CPT","20000490","CDM","360","RC","","Facility","Outpatient","","","2428","1942.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1262.56","52","","","Percent of Total Billed Charges","neg_dollar:$1262.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1262.56","52","","","Percent of Total Billed Charges","neg_dollar:$1262.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1262.56","52","","","Percent of Total Billed Charges","neg_dollar:$1262.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1262.56","52","","","Percent of Total Billed Charges","neg_dollar:$1262.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","2088.08","86","","","Percent of Total Billed Charges","neg_dollar:$2088.08","1699.60","70","","","Percent of Total Billed Charges","neg_dollar:$1699.60","1262.56","52","","","Percent of Total Billed Charges","neg_dollar:$1262.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","1426.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$1426.44;102% of Medicaid interim rate","1821.00","75","","","Percent of Total Billed Charges","neg_dollar:$1821","2088.08","86","","","Percent of Total Billed Charges","neg_dollar:$2088.08","1699.60","70","","","Percent of Total Billed Charges","neg_dollar:$1699.60","1383.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$1383.95;103.5% of Medicaid interim rate","2428.00","150","","","Percent of Total Billed Charges","neg_dollar:$3753.80;150% of Medicaid interim rate","1942.40","80","","","Percent of Total Billed Charges","neg_dollar:$1942.40;Percent of Total Billed Charges","2233.76","92","","","Percent of Total Billed Charges","neg_dollar:$2233.76","1262.56","52","","","Percent of Total Billed Charges","neg_dollar:$1262.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1262.56","52","","","Percent of Total Billed Charges","neg_dollar:$1262.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2428.00",""
"EXTENSOR TENDON REPAIR FINGER EACH","26418","CPT","20000042","CDM","360","RC","","Facility","Outpatient","","","2578","2062.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1340.56","52","","","Percent of Total Billed Charges","neg_dollar:$1340.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1340.56","52","","","Percent of Total Billed Charges","neg_dollar:$1340.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1340.56","52","","","Percent of Total Billed Charges","neg_dollar:$1340.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1340.56","52","","","Percent of Total Billed Charges","neg_dollar:$1340.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","2217.08","86","","","Percent of Total Billed Charges","neg_dollar:$2217.08","1804.60","70","","","Percent of Total Billed Charges","neg_dollar:$1804.60","1340.56","52","","","Percent of Total Billed Charges","neg_dollar:$1340.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","1514.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$1514.57;102% of Medicaid interim rate","1933.50","75","","","Percent of Total Billed Charges","neg_dollar:$1933.50","2217.08","86","","","Percent of Total Billed Charges","neg_dollar:$2217.08","1804.60","70","","","Percent of Total Billed Charges","neg_dollar:$1804.60","1469.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$1469.45;103.5% of Medicaid interim rate","2578.00","150","","","Percent of Total Billed Charges","neg_dollar:$3985.71;150% of Medicaid interim rate","2062.40","80","","","Percent of Total Billed Charges","neg_dollar:$2062.40;Percent of Total Billed Charges","2371.76","92","","","Percent of Total Billed Charges","neg_dollar:$2371.76","1340.56","52","","","Percent of Total Billed Charges","neg_dollar:$1340.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1340.56","52","","","Percent of Total Billed Charges","neg_dollar:$1340.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2578.00",""
"CL TX MC FX SGL W MANIP","26605","CPT","20000044","CDM","450","RC","","Facility","Outpatient","","","1006","804.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","523.12","52","","","Percent of Total Billed Charges","neg_dollar:$523.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","523.12","52","","","Percent of Total Billed Charges","neg_dollar:$523.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","523.12","52","","","Percent of Total Billed Charges","neg_dollar:$523.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","523.12","52","","","Percent of Total Billed Charges","neg_dollar:$523.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","865.16","86","","","Percent of Total Billed Charges","neg_dollar:$865.16","704.19","70","","","Percent of Total Billed Charges","neg_dollar:$704.19","523.12","52","","","Percent of Total Billed Charges","neg_dollar:$523.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","591.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$591.02;102% of Medicaid interim rate","754.50","75","","","Percent of Total Billed Charges","neg_dollar:$754.50","865.16","86","","","Percent of Total Billed Charges","neg_dollar:$865.16","704.19","70","","","Percent of Total Billed Charges","neg_dollar:$704.19","573.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$573.42;103.5% of Medicaid interim rate","1006.00","150","","","Percent of Total Billed Charges","neg_dollar:$1555.32;150% of Medicaid interim rate","804.80","80","","","Percent of Total Billed Charges","neg_dollar:$804.80;Percent of Total Billed Charges","925.52","92","","","Percent of Total Billed Charges","neg_dollar:$925.52","523.12","52","","","Percent of Total Billed Charges","neg_dollar:$523.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","523.12","52","","","Percent of Total Billed Charges","neg_dollar:$523.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","523.00","1006.00",""
"CL TX PHALANG SHFT FX W MANIP","26725","CPT","20000049","CDM","450","RC","","Facility","Outpatient","","","744","595.20","744.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","386.88","52","","","Percent of Total Billed Charges","neg_dollar:$386.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","744.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","386.88","52","","","Percent of Total Billed Charges","neg_dollar:$386.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","386.88","52","","","Percent of Total Billed Charges","neg_dollar:$386.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","386.88","52","","","Percent of Total Billed Charges","neg_dollar:$386.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","639.84","86","","","Percent of Total Billed Charges","neg_dollar:$639.84","520.80","70","","","Percent of Total Billed Charges","neg_dollar:$520.80","386.88","52","","","Percent of Total Billed Charges","neg_dollar:$386.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","437.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$437.09;102% of Medicaid interim rate","558.00","75","","","Percent of Total Billed Charges","neg_dollar:$558","639.84","86","","","Percent of Total Billed Charges","neg_dollar:$639.84","520.80","70","","","Percent of Total Billed Charges","neg_dollar:$520.80","424.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$424.08;103.5% of Medicaid interim rate","744.00","150","","","Percent of Total Billed Charges","neg_dollar:$1150.26;150% of Medicaid interim rate","595.20","80","","","Percent of Total Billed Charges","neg_dollar:$595.20;Percent of Total Billed Charges","684.48","92","","","Percent of Total Billed Charges","neg_dollar:$684.48","386.88","52","","","Percent of Total Billed Charges","neg_dollar:$386.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","386.88","52","","","Percent of Total Billed Charges","neg_dollar:$386.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","386.00","744.00",""
"CL TX ART FX MCP/IP JNT W MANIP","26742","CPT","20000050","CDM","450","RC","","Facility","Outpatient","","","860","688.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","505.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$505.24;102% of Medicaid interim rate","645.00","75","","","Percent of Total Billed Charges","neg_dollar:$645","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","490.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$490.19;103.5% of Medicaid interim rate","860.00","150","","","Percent of Total Billed Charges","neg_dollar:$1329.60;150% of Medicaid interim rate","688.00","80","","","Percent of Total Billed Charges","neg_dollar:$688;Percent of Total Billed Charges","791.20","92","","","Percent of Total Billed Charges","neg_dollar:$791.20","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","447.00","860.00",""
"CL TX D PHAL FX FGR/THMB W MANIP","26755","CPT","20000052","CDM","450","RC","","Facility","Outpatient","","","424","339.20","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","249.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.09;102% of Medicaid interim rate","318.00","75","","","Percent of Total Billed Charges","neg_dollar:$318","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","241.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$241.67;103.5% of Medicaid interim rate","424.00","150","","","Percent of Total Billed Charges","neg_dollar:$655.52;150% of Medicaid interim rate","339.20","80","","","Percent of Total Billed Charges","neg_dollar:$339.20;Percent of Total Billed Charges","390.08","92","","","Percent of Total Billed Charges","neg_dollar:$390.08","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.00","424.00",""
"OPEN TX D PHAL FX FGR/THMB EACH","26765","CPT","20000149","CDM","450","RC","","Facility","Outpatient","","","7214","5771.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","3751.28","52","","","Percent of Total Billed Charges","neg_dollar:$3751.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","3751.28","52","","","Percent of Total Billed Charges","neg_dollar:$3751.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","3751.28","52","","","Percent of Total Billed Charges","neg_dollar:$3751.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","3751.28","52","","","Percent of Total Billed Charges","neg_dollar:$3751.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","6204.04","86","","","Percent of Total Billed Charges","neg_dollar:$6204.04","5049.79","70","","","Percent of Total Billed Charges","neg_dollar:$5049.79","3751.28","52","","","Percent of Total Billed Charges","neg_dollar:$3751.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","4238.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$4238.21;102% of Medicaid interim rate","5410.50","75","","","Percent of Total Billed Charges","neg_dollar:$5410.50","6204.04","86","","","Percent of Total Billed Charges","neg_dollar:$6204.04","5049.79","70","","","Percent of Total Billed Charges","neg_dollar:$5049.79","4111.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$4111.98;103.5% of Medicaid interim rate","7214.00","150","","","Percent of Total Billed Charges","neg_dollar:$11153.20;150% of Medicaid interim rate","5771.20","80","","","Percent of Total Billed Charges","neg_dollar:$5771.20;Percent of Total Billed Charges","6636.88","92","","","Percent of Total Billed Charges","neg_dollar:$6636.88","3751.28","52","","","Percent of Total Billed Charges","neg_dollar:$3751.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","3751.28","52","","","Percent of Total Billed Charges","neg_dollar:$3751.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","7214.00",""
"CL TX IP JNT D W MANIP WO ANESTH","26770","CPT","20000053","CDM","450","RC","","Facility","Outpatient","","","656","524.80","656.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","341.12","52","","","Percent of Total Billed Charges","neg_dollar:$341.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","656.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","341.12","52","","","Percent of Total Billed Charges","neg_dollar:$341.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","341.12","52","","","Percent of Total Billed Charges","neg_dollar:$341.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","341.12","52","","","Percent of Total Billed Charges","neg_dollar:$341.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","564.16","86","","","Percent of Total Billed Charges","neg_dollar:$564.16","459.20","70","","","Percent of Total Billed Charges","neg_dollar:$459.20","341.12","52","","","Percent of Total Billed Charges","neg_dollar:$341.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","385.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$385.39;102% of Medicaid interim rate","492.00","75","","","Percent of Total Billed Charges","neg_dollar:$492","564.16","86","","","Percent of Total Billed Charges","neg_dollar:$564.16","459.20","70","","","Percent of Total Billed Charges","neg_dollar:$459.20","373.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$373.91;103.5% of Medicaid interim rate","656.00","150","","","Percent of Total Billed Charges","neg_dollar:$1014.20;150% of Medicaid interim rate","524.80","80","","","Percent of Total Billed Charges","neg_dollar:$524.80;Percent of Total Billed Charges","603.52","92","","","Percent of Total Billed Charges","neg_dollar:$603.52","341.12","52","","","Percent of Total Billed Charges","neg_dollar:$341.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","341.12","52","","","Percent of Total Billed Charges","neg_dollar:$341.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","341.00","656.00",""
"INJ ARTHROGRAM HIP W/O ANESTH","27093","CPT","20000192","CDM","360","RC","","Facility","Outpatient","","","463","370.40","463.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","240.76","52","","","Percent of Total Billed Charges","neg_dollar:$240.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","463.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","240.76","52","","","Percent of Total Billed Charges","neg_dollar:$240.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","240.76","52","","","Percent of Total Billed Charges","neg_dollar:$240.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","240.76","52","","","Percent of Total Billed Charges","neg_dollar:$240.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","398.18","86","","","Percent of Total Billed Charges","neg_dollar:$398.18","324.09","70","","","Percent of Total Billed Charges","neg_dollar:$324.09","240.76","52","","","Percent of Total Billed Charges","neg_dollar:$240.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","272.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$272.01;102% of Medicaid interim rate","347.25","75","","","Percent of Total Billed Charges","neg_dollar:$347.25","398.18","86","","","Percent of Total Billed Charges","neg_dollar:$398.18","324.09","70","","","Percent of Total Billed Charges","neg_dollar:$324.09","263.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$263.90;103.5% of Medicaid interim rate","463.00","150","","","Percent of Total Billed Charges","neg_dollar:$715.82;150% of Medicaid interim rate","370.40","80","","","Percent of Total Billed Charges","neg_dollar:$370.40;Percent of Total Billed Charges","425.96","92","","","Percent of Total Billed Charges","neg_dollar:$425.96","240.76","52","","","Percent of Total Billed Charges","neg_dollar:$240.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","240.76","52","","","Percent of Total Billed Charges","neg_dollar:$240.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","240.00","463.00",""
"SIJ ANESTH/STERIOD INJ PAIN","27096","CPT","20000119","CDM","761","RC","","Facility","Outpatient","","","2115","1692.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1099.80","52","","","Percent of Total Billed Charges","neg_dollar:$1099.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1099.80","52","","","Percent of Total Billed Charges","neg_dollar:$1099.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1099.80","52","","","Percent of Total Billed Charges","neg_dollar:$1099.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1099.80","52","","","Percent of Total Billed Charges","neg_dollar:$1099.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1818.89","86","","","Percent of Total Billed Charges","neg_dollar:$1818.89","1480.50","70","","","Percent of Total Billed Charges","neg_dollar:$1480.50","1099.80","52","","","Percent of Total Billed Charges","neg_dollar:$1099.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","1242.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$1242.56;102% of Medicaid interim rate","1586.25","75","","","Percent of Total Billed Charges","neg_dollar:$1586.25","1818.89","86","","","Percent of Total Billed Charges","neg_dollar:$1818.89","1480.50","70","","","Percent of Total Billed Charges","neg_dollar:$1480.50","1205.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$1205.55;103.5% of Medicaid interim rate","2115.00","150","","","Percent of Total Billed Charges","neg_dollar:$3269.89;150% of Medicaid interim rate","1692.00","80","","","Percent of Total Billed Charges","neg_dollar:$1692;Percent of Total Billed Charges","1945.80","92","","","Percent of Total Billed Charges","neg_dollar:$1945.80","1099.80","52","","","Percent of Total Billed Charges","neg_dollar:$1099.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1099.80","52","","","Percent of Total Billed Charges","neg_dollar:$1099.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2115.00",""
"SIJ ANESTH/STERIOD INJ PAIN BILAT","27096","CPT","20000120","CDM","761","RC","50","Facility","Outpatient","","","3170","2536.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1648.40","52","","","Percent of Total Billed Charges","neg_dollar:$1648.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1648.40","52","","","Percent of Total Billed Charges","neg_dollar:$1648.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1648.40","52","","","Percent of Total Billed Charges","neg_dollar:$1648.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1648.40","52","","","Percent of Total Billed Charges","neg_dollar:$1648.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2726.20","86","","","Percent of Total Billed Charges","neg_dollar:$2726.20","2219.00","70","","","Percent of Total Billed Charges","neg_dollar:$2219","1648.40","52","","","Percent of Total Billed Charges","neg_dollar:$1648.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","1862.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$1862.37;102% of Medicaid interim rate","2377.50","75","","","Percent of Total Billed Charges","neg_dollar:$2377.50","2726.20","86","","","Percent of Total Billed Charges","neg_dollar:$2726.20","2219.00","70","","","Percent of Total Billed Charges","neg_dollar:$2219","1806.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$1806.89;103.5% of Medicaid interim rate","3170.00","150","","","Percent of Total Billed Charges","neg_dollar:$4900.97;150% of Medicaid interim rate","2536.00","80","","","Percent of Total Billed Charges","neg_dollar:$2536;Percent of Total Billed Charges","2916.40","92","","","Percent of Total Billed Charges","neg_dollar:$2916.40","1648.40","52","","","Percent of Total Billed Charges","neg_dollar:$1648.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1648.40","52","","","Percent of Total Billed Charges","neg_dollar:$1648.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3170.00",""
"DX INJ SI JOINT ARTHROGRAPHY","27096","CPT","20000337","CDM","761","RC","","Facility","Outpatient","","","1318","1054.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","774.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$774.32;102% of Medicaid interim rate","988.50","75","","","Percent of Total Billed Charges","neg_dollar:$988.50","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","751.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$751.26;103.5% of Medicaid interim rate","1318.00","150","","","Percent of Total Billed Charges","neg_dollar:$2037.69;150% of Medicaid interim rate","1054.40","80","","","Percent of Total Billed Charges","neg_dollar:$1054.40;Percent of Total Billed Charges","1212.56","92","","","Percent of Total Billed Charges","neg_dollar:$1212.56","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","685.00","1318.00",""
"CL TX POST HIP DISLOC WO ANESTH","27265","CPT","20000058","CDM","450","RC","","Facility","Outpatient","","","1308","1046.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","680.16","52","","","Percent of Total Billed Charges","neg_dollar:$680.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","680.16","52","","","Percent of Total Billed Charges","neg_dollar:$680.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","680.16","52","","","Percent of Total Billed Charges","neg_dollar:$680.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","680.16","52","","","Percent of Total Billed Charges","neg_dollar:$680.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1124.87","86","","","Percent of Total Billed Charges","neg_dollar:$1124.87","915.59","70","","","Percent of Total Billed Charges","neg_dollar:$915.59","680.16","52","","","Percent of Total Billed Charges","neg_dollar:$680.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","768.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$768.44;102% of Medicaid interim rate","981.00","75","","","Percent of Total Billed Charges","neg_dollar:$981","1124.87","86","","","Percent of Total Billed Charges","neg_dollar:$1124.87","915.59","70","","","Percent of Total Billed Charges","neg_dollar:$915.59","745.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$745.56;103.5% of Medicaid interim rate","1308.00","150","","","Percent of Total Billed Charges","neg_dollar:$2022.23;150% of Medicaid interim rate","1046.40","80","","","Percent of Total Billed Charges","neg_dollar:$1046.40;Percent of Total Billed Charges","1203.36","92","","","Percent of Total Billed Charges","neg_dollar:$1203.36","680.16","52","","","Percent of Total Billed Charges","neg_dollar:$680.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","680.16","52","","","Percent of Total Billed Charges","neg_dollar:$680.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","680.00","1308.00",""
"CL TX FEMORAL SHAFT FX W MANIP","27502","CPT","20000259","CDM","450","RC","","Facility","Outpatient","","","2922","2337.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1519.44","52","","","Percent of Total Billed Charges","neg_dollar:$1519.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1519.44","52","","","Percent of Total Billed Charges","neg_dollar:$1519.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","1519.44","52","","","Percent of Total Billed Charges","neg_dollar:$1519.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","1519.44","52","","","Percent of Total Billed Charges","neg_dollar:$1519.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","2512.92","86","","","Percent of Total Billed Charges","neg_dollar:$2512.92","2045.39","70","","","Percent of Total Billed Charges","neg_dollar:$2045.39","1519.44","52","","","Percent of Total Billed Charges","neg_dollar:$1519.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","1716.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$1716.67;102% of Medicaid interim rate","2191.50","75","","","Percent of Total Billed Charges","neg_dollar:$2191.50","2512.92","86","","","Percent of Total Billed Charges","neg_dollar:$2512.92","2045.39","70","","","Percent of Total Billed Charges","neg_dollar:$2045.39","1665.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$1665.54;103.5% of Medicaid interim rate","2922.00","150","","","Percent of Total Billed Charges","neg_dollar:$4517.55;150% of Medicaid interim rate","2337.60","80","","","Percent of Total Billed Charges","neg_dollar:$2337.60;Percent of Total Billed Charges","2688.24","92","","","Percent of Total Billed Charges","neg_dollar:$2688.24","1519.44","52","","","Percent of Total Billed Charges","neg_dollar:$1519.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","1519.44","52","","","Percent of Total Billed Charges","neg_dollar:$1519.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2922.00",""
"CL TX PATELLAR DISLOCATION WO ANESTH","27560","CPT","20000063","CDM","450","RC","","Facility","Outpatient","","","284","227.20","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","166.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$166.84;102% of Medicaid interim rate","213.00","75","","","Percent of Total Billed Charges","neg_dollar:$213","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","161.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$161.88;103.5% of Medicaid interim rate","284.00","150","","","Percent of Total Billed Charges","neg_dollar:$439.07;150% of Medicaid interim rate","227.20","80","","","Percent of Total Billed Charges","neg_dollar:$227.20;Percent of Total Billed Charges","261.28","92","","","Percent of Total Billed Charges","neg_dollar:$261.28","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.00","284.00",""
"CL TX BIMALLEOLAR ANKLE FX W MANIP","27810","CPT","20000073","CDM","450","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"CL TX TRIMALL ANKLE FX W MANIP","27818","CPT","20000075","CDM","450","RC","","Facility","Outpatient","","","1594","1275.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","828.88","52","","","Percent of Total Billed Charges","neg_dollar:$828.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","828.88","52","","","Percent of Total Billed Charges","neg_dollar:$828.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","828.88","52","","","Percent of Total Billed Charges","neg_dollar:$828.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","828.88","52","","","Percent of Total Billed Charges","neg_dollar:$828.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1370.84","86","","","Percent of Total Billed Charges","neg_dollar:$1370.84","1115.80","70","","","Percent of Total Billed Charges","neg_dollar:$1115.80","828.88","52","","","Percent of Total Billed Charges","neg_dollar:$828.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","936.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$936.47;102% of Medicaid interim rate","1195.50","75","","","Percent of Total Billed Charges","neg_dollar:$1195.50","1370.84","86","","","Percent of Total Billed Charges","neg_dollar:$1370.84","1115.80","70","","","Percent of Total Billed Charges","neg_dollar:$1115.80","908.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$908.57;103.5% of Medicaid interim rate","1594.00","150","","","Percent of Total Billed Charges","neg_dollar:$2464.40;150% of Medicaid interim rate","1275.20","80","","","Percent of Total Billed Charges","neg_dollar:$1275.20;Percent of Total Billed Charges","1466.48","92","","","Percent of Total Billed Charges","neg_dollar:$1466.48","828.88","52","","","Percent of Total Billed Charges","neg_dollar:$828.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","828.88","52","","","Percent of Total Billed Charges","neg_dollar:$828.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1594.00",""
"REM FB FOOT SQ","28190","CPT","20000117","CDM","360","RC","","Facility","Outpatient","","","2101","1680.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1092.52","52","","","Percent of Total Billed Charges","neg_dollar:$1092.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1092.52","52","","","Percent of Total Billed Charges","neg_dollar:$1092.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1092.52","52","","","Percent of Total Billed Charges","neg_dollar:$1092.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1092.52","52","","","Percent of Total Billed Charges","neg_dollar:$1092.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1806.86","86","","","Percent of Total Billed Charges","neg_dollar:$1806.86","1470.69","70","","","Percent of Total Billed Charges","neg_dollar:$1470.69","1092.52","52","","","Percent of Total Billed Charges","neg_dollar:$1092.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","1234.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$1234.33;102% of Medicaid interim rate","1575.75","75","","","Percent of Total Billed Charges","neg_dollar:$1575.75","1806.86","86","","","Percent of Total Billed Charges","neg_dollar:$1806.86","1470.69","70","","","Percent of Total Billed Charges","neg_dollar:$1470.69","1197.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$1197.57;103.5% of Medicaid interim rate","2101.00","150","","","Percent of Total Billed Charges","neg_dollar:$3248.25;150% of Medicaid interim rate","1680.80","80","","","Percent of Total Billed Charges","neg_dollar:$1680.80;Percent of Total Billed Charges","1932.92","92","","","Percent of Total Billed Charges","neg_dollar:$1932.92","1092.52","52","","","Percent of Total Billed Charges","neg_dollar:$1092.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1092.52","52","","","Percent of Total Billed Charges","neg_dollar:$1092.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2101.00",""
"CL TX TALUS FX W MANIP","28435","CPT","20000210","CDM","450","RC","","Facility","Outpatient","","","355","284.00","355.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","355.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","208.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$208.56;102% of Medicaid interim rate","266.25","75","","","Percent of Total Billed Charges","neg_dollar:$266.25","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","202.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$202.35;103.5% of Medicaid interim rate","355.00","150","","","Percent of Total Billed Charges","neg_dollar:$548.84;150% of Medicaid interim rate","284.00","80","","","Percent of Total Billed Charges","neg_dollar:$284;Percent of Total Billed Charges","326.60","92","","","Percent of Total Billed Charges","neg_dollar:$326.60","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.00","355.00",""
"CL TX FX GT PHALANX W MANIP","28495","CPT","20000085","CDM","450","RC","","Facility","Outpatient","","","355","284.00","355.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","355.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","208.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$208.56;102% of Medicaid interim rate","266.25","75","","","Percent of Total Billed Charges","neg_dollar:$266.25","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","202.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$202.35;103.5% of Medicaid interim rate","355.00","150","","","Percent of Total Billed Charges","neg_dollar:$548.84;150% of Medicaid interim rate","284.00","80","","","Percent of Total Billed Charges","neg_dollar:$284;Percent of Total Billed Charges","326.60","92","","","Percent of Total Billed Charges","neg_dollar:$326.60","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.00","355.00",""
"CL TX FX PHALANX/PHALANG W MANIP","28515","CPT","20000087","CDM","450","RC","","Facility","Outpatient","","","659","527.20","659.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","342.68","52","","","Percent of Total Billed Charges","neg_dollar:$342.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","659.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","342.68","52","","","Percent of Total Billed Charges","neg_dollar:$342.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","342.68","52","","","Percent of Total Billed Charges","neg_dollar:$342.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","342.68","52","","","Percent of Total Billed Charges","neg_dollar:$342.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","566.74","86","","","Percent of Total Billed Charges","neg_dollar:$566.74","461.29","70","","","Percent of Total Billed Charges","neg_dollar:$461.29","342.68","52","","","Percent of Total Billed Charges","neg_dollar:$342.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","387.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$387.16;102% of Medicaid interim rate","494.25","75","","","Percent of Total Billed Charges","neg_dollar:$494.25","566.74","86","","","Percent of Total Billed Charges","neg_dollar:$566.74","461.29","70","","","Percent of Total Billed Charges","neg_dollar:$461.29","375.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$375.63;103.5% of Medicaid interim rate","659.00","150","","","Percent of Total Billed Charges","neg_dollar:$1018.84;150% of Medicaid interim rate","527.20","80","","","Percent of Total Billed Charges","neg_dollar:$527.20;Percent of Total Billed Charges","606.28","92","","","Percent of Total Billed Charges","neg_dollar:$606.28","342.68","52","","","Percent of Total Billed Charges","neg_dollar:$342.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","342.68","52","","","Percent of Total Billed Charges","neg_dollar:$342.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","342.00","659.00",""
"AMPUTATE TOE; MTP JOINT","28820","CPT","20000267","CDM","761","RC","","Facility","Outpatient","","","1863","1490.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","968.76","52","","","Percent of Total Billed Charges","neg_dollar:$968.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","968.76","52","","","Percent of Total Billed Charges","neg_dollar:$968.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","968.76","52","","","Percent of Total Billed Charges","neg_dollar:$968.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","968.76","52","","","Percent of Total Billed Charges","neg_dollar:$968.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1602.18","86","","","Percent of Total Billed Charges","neg_dollar:$1602.18","1304.10","70","","","Percent of Total Billed Charges","neg_dollar:$1304.10","968.76","52","","","Percent of Total Billed Charges","neg_dollar:$968.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","1094.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$1094.51;102% of Medicaid interim rate","1397.25","75","","","Percent of Total Billed Charges","neg_dollar:$1397.25","1602.18","86","","","Percent of Total Billed Charges","neg_dollar:$1602.18","1304.10","70","","","Percent of Total Billed Charges","neg_dollar:$1304.10","1061.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$1061.90;103.5% of Medicaid interim rate","1863.00","150","","","Percent of Total Billed Charges","neg_dollar:$2880.29;150% of Medicaid interim rate","1490.40","80","","","Percent of Total Billed Charges","neg_dollar:$1490.40;Percent of Total Billed Charges","1713.96","92","","","Percent of Total Billed Charges","neg_dollar:$1713.96","968.76","52","","","Percent of Total Billed Charges","neg_dollar:$968.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","968.76","52","","","Percent of Total Billed Charges","neg_dollar:$968.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1863.00",""
"APPLY SHORT ARM CAST","29075","CPT","20000092","CDM","360","RC","","Facility","Outpatient","","","297","237.60","297.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","297.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","174.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$174.48;102% of Medicaid interim rate","222.75","75","","","Percent of Total Billed Charges","neg_dollar:$222.75","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","169.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$169.29;103.5% of Medicaid interim rate","297.00","150","","","Percent of Total Billed Charges","neg_dollar:$459.17;150% of Medicaid interim rate","237.60","80","","","Percent of Total Billed Charges","neg_dollar:$237.60;Percent of Total Billed Charges","273.24","92","","","Percent of Total Billed Charges","neg_dollar:$273.24","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","154.00","297.00",""
"APPLY LONG ARM SPLINT","29105","CPT","20000094","CDM","360","RC","","Facility","Outpatient","","","292","233.60","292.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","292.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","251.12","86","","","Percent of Total Billed Charges","neg_dollar:$251.12","204.39","70","","","Percent of Total Billed Charges","neg_dollar:$204.39","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","171.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$171.54;102% of Medicaid interim rate","219.00","75","","","Percent of Total Billed Charges","neg_dollar:$219","251.12","86","","","Percent of Total Billed Charges","neg_dollar:$251.12","204.39","70","","","Percent of Total Billed Charges","neg_dollar:$204.39","166.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$166.44;103.5% of Medicaid interim rate","292.00","150","","","Percent of Total Billed Charges","neg_dollar:$451.44;150% of Medicaid interim rate","233.60","80","","","Percent of Total Billed Charges","neg_dollar:$233.60;Percent of Total Billed Charges","268.64","92","","","Percent of Total Billed Charges","neg_dollar:$268.64","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","151.00","292.00",""
"APPLY SHORT ARM SPLINT STATIC","29125","CPT","20000095","CDM","360","RC","","Facility","Outpatient","","","297","237.60","297.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","297.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","174.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$174.48;102% of Medicaid interim rate","222.75","75","","","Percent of Total Billed Charges","neg_dollar:$222.75","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","169.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$169.29;103.5% of Medicaid interim rate","297.00","150","","","Percent of Total Billed Charges","neg_dollar:$459.17;150% of Medicaid interim rate","237.60","80","","","Percent of Total Billed Charges","neg_dollar:$237.60;Percent of Total Billed Charges","273.24","92","","","Percent of Total Billed Charges","neg_dollar:$273.24","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","154.00","297.00",""
"APPLY SHORT ARM SPLINT DYNAMIC","29126","CPT","20000299","CDM","761","RC","","Facility","Outpatient","","","171","136.80","171.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","88.92","52","","","Percent of Total Billed Charges","neg_dollar:$88.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","171.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","88.92","52","","","Percent of Total Billed Charges","neg_dollar:$88.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.92","52","","","Percent of Total Billed Charges","neg_dollar:$88.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.92","52","","","Percent of Total Billed Charges","neg_dollar:$88.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.06","86","","","Percent of Total Billed Charges","neg_dollar:$147.06","119.69","70","","","Percent of Total Billed Charges","neg_dollar:$119.69","88.92","52","","","Percent of Total Billed Charges","neg_dollar:$88.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","100.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$100.46;102% of Medicaid interim rate","128.25","75","","","Percent of Total Billed Charges","neg_dollar:$128.25","147.06","86","","","Percent of Total Billed Charges","neg_dollar:$147.06","119.69","70","","","Percent of Total Billed Charges","neg_dollar:$119.69","97.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$97.46;103.5% of Medicaid interim rate","171.00","150","","","Percent of Total Billed Charges","neg_dollar:$264.37;150% of Medicaid interim rate","136.80","80","","","Percent of Total Billed Charges","neg_dollar:$136.80;Percent of Total Billed Charges","157.32","92","","","Percent of Total Billed Charges","neg_dollar:$157.32","88.92","52","","","Percent of Total Billed Charges","neg_dollar:$88.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","88.92","52","","","Percent of Total Billed Charges","neg_dollar:$88.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","88.00","171.00",""
"APPLY FINGER SPLINT STATIC","29130","CPT","20000096","CDM","360","RC","","Facility","Outpatient","","","170","136.00","170.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","170.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","146.20","86","","","Percent of Total Billed Charges","neg_dollar:$146.20","118.99","70","","","Percent of Total Billed Charges","neg_dollar:$118.99","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","99.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$99.87;102% of Medicaid interim rate","127.50","75","","","Percent of Total Billed Charges","neg_dollar:$127.50","146.20","86","","","Percent of Total Billed Charges","neg_dollar:$146.20","118.99","70","","","Percent of Total Billed Charges","neg_dollar:$118.99","96.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$96.89;103.5% of Medicaid interim rate","170.00","150","","","Percent of Total Billed Charges","neg_dollar:$262.82;150% of Medicaid interim rate","136.00","80","","","Percent of Total Billed Charges","neg_dollar:$136;Percent of Total Billed Charges","156.40","92","","","Percent of Total Billed Charges","neg_dollar:$156.40","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","88.00","170.00",""
"APPLY FINGER SPLINT DYNAMIC","29131","CPT","20000300","CDM","761","RC","","Facility","Outpatient","","","113","90.40","113.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","113.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","97.17","86","","","Percent of Total Billed Charges","neg_dollar:$97.17","79.10","70","","","Percent of Total Billed Charges","neg_dollar:$79.10","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","66.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.38;102% of Medicaid interim rate","84.75","75","","","Percent of Total Billed Charges","neg_dollar:$84.75","97.17","86","","","Percent of Total Billed Charges","neg_dollar:$97.17","79.10","70","","","Percent of Total Billed Charges","neg_dollar:$79.10","64.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.41;103.5% of Medicaid interim rate","113.00","150","","","Percent of Total Billed Charges","neg_dollar:$174.70;150% of Medicaid interim rate","90.40","80","","","Percent of Total Billed Charges","neg_dollar:$90.40;Percent of Total Billed Charges","103.96","92","","","Percent of Total Billed Charges","neg_dollar:$103.96","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.00","113.00",""
"APPLY RIGID TOTAL CONTACT LEG CAST","29445","CPT","20000102","CDM","761","RC","","Facility","Outpatient","","","524","419.20","524.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","272.48","52","","","Percent of Total Billed Charges","neg_dollar:$272.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","524.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","272.48","52","","","Percent of Total Billed Charges","neg_dollar:$272.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","272.48","52","","","Percent of Total Billed Charges","neg_dollar:$272.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","272.48","52","","","Percent of Total Billed Charges","neg_dollar:$272.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","450.64","86","","","Percent of Total Billed Charges","neg_dollar:$450.64","366.79","70","","","Percent of Total Billed Charges","neg_dollar:$366.79","272.48","52","","","Percent of Total Billed Charges","neg_dollar:$272.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","307.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$307.84;102% of Medicaid interim rate","393.00","75","","","Percent of Total Billed Charges","neg_dollar:$393","450.64","86","","","Percent of Total Billed Charges","neg_dollar:$450.64","366.79","70","","","Percent of Total Billed Charges","neg_dollar:$366.79","298.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$298.67;103.5% of Medicaid interim rate","524.00","150","","","Percent of Total Billed Charges","neg_dollar:$810.13;150% of Medicaid interim rate","419.20","80","","","Percent of Total Billed Charges","neg_dollar:$419.20;Percent of Total Billed Charges","482.08","92","","","Percent of Total Billed Charges","neg_dollar:$482.08","272.48","52","","","Percent of Total Billed Charges","neg_dollar:$272.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","272.48","52","","","Percent of Total Billed Charges","neg_dollar:$272.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","272.00","524.00",""
"APPLY LONG LEG SPLINT","29505","CPT","20000103","CDM","360","RC","","Facility","Outpatient","","","222","177.60","222.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","115.44","52","","","Percent of Total Billed Charges","neg_dollar:$115.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","222.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","115.44","52","","","Percent of Total Billed Charges","neg_dollar:$115.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","115.44","52","","","Percent of Total Billed Charges","neg_dollar:$115.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","115.44","52","","","Percent of Total Billed Charges","neg_dollar:$115.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","190.92","86","","","Percent of Total Billed Charges","neg_dollar:$190.92","155.39","70","","","Percent of Total Billed Charges","neg_dollar:$155.39","115.44","52","","","Percent of Total Billed Charges","neg_dollar:$115.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","130.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$130.42;102% of Medicaid interim rate","166.50","75","","","Percent of Total Billed Charges","neg_dollar:$166.50","190.92","86","","","Percent of Total Billed Charges","neg_dollar:$190.92","155.39","70","","","Percent of Total Billed Charges","neg_dollar:$155.39","126.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$126.53;103.5% of Medicaid interim rate","222.00","150","","","Percent of Total Billed Charges","neg_dollar:$343.22;150% of Medicaid interim rate","177.60","80","","","Percent of Total Billed Charges","neg_dollar:$177.60;Percent of Total Billed Charges","204.24","92","","","Percent of Total Billed Charges","neg_dollar:$204.24","115.44","52","","","Percent of Total Billed Charges","neg_dollar:$115.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","115.44","52","","","Percent of Total Billed Charges","neg_dollar:$115.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","115.00","222.00",""
"APPLY SHORT LEG SPLINT","29515","CPT","20000104","CDM","360","RC","","Facility","Outpatient","","","198","158.40","198.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","102.96","52","","","Percent of Total Billed Charges","neg_dollar:$102.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","198.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","102.96","52","","","Percent of Total Billed Charges","neg_dollar:$102.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","102.96","52","","","Percent of Total Billed Charges","neg_dollar:$102.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","102.96","52","","","Percent of Total Billed Charges","neg_dollar:$102.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","170.28","86","","","Percent of Total Billed Charges","neg_dollar:$170.28","138.60","70","","","Percent of Total Billed Charges","neg_dollar:$138.60","102.96","52","","","Percent of Total Billed Charges","neg_dollar:$102.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","116.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$116.32;102% of Medicaid interim rate","148.50","75","","","Percent of Total Billed Charges","neg_dollar:$148.50","170.28","86","","","Percent of Total Billed Charges","neg_dollar:$170.28","138.60","70","","","Percent of Total Billed Charges","neg_dollar:$138.60","112.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$112.85;103.5% of Medicaid interim rate","198.00","150","","","Percent of Total Billed Charges","neg_dollar:$306.11;150% of Medicaid interim rate","158.40","80","","","Percent of Total Billed Charges","neg_dollar:$158.40;Percent of Total Billed Charges","182.16","92","","","Percent of Total Billed Charges","neg_dollar:$182.16","102.96","52","","","Percent of Total Billed Charges","neg_dollar:$102.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","102.96","52","","","Percent of Total Billed Charges","neg_dollar:$102.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","102.00","198.00",""
"UNNA BOOT STRAPPING","29580","CPT","20000106","CDM","761","RC","","Facility","Outpatient","","","482","385.60","482.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","250.64","52","","","Percent of Total Billed Charges","neg_dollar:$250.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","482.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","250.64","52","","","Percent of Total Billed Charges","neg_dollar:$250.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","250.64","52","","","Percent of Total Billed Charges","neg_dollar:$250.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","250.64","52","","","Percent of Total Billed Charges","neg_dollar:$250.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","414.52","86","","","Percent of Total Billed Charges","neg_dollar:$414.52","337.40","70","","","Percent of Total Billed Charges","neg_dollar:$337.40","250.64","52","","","Percent of Total Billed Charges","neg_dollar:$250.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","283.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$283.17;102% of Medicaid interim rate","361.50","75","","","Percent of Total Billed Charges","neg_dollar:$361.50","414.52","86","","","Percent of Total Billed Charges","neg_dollar:$414.52","337.40","70","","","Percent of Total Billed Charges","neg_dollar:$337.40","274.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$274.73;103.5% of Medicaid interim rate","482.00","150","","","Percent of Total Billed Charges","neg_dollar:$745.19;150% of Medicaid interim rate","385.60","80","","","Percent of Total Billed Charges","neg_dollar:$385.60;Percent of Total Billed Charges","443.44","92","","","Percent of Total Billed Charges","neg_dollar:$443.44","250.64","52","","","Percent of Total Billed Charges","neg_dollar:$250.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","250.64","52","","","Percent of Total Billed Charges","neg_dollar:$250.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","250.00","482.00",""
"APPLY MULTLAY COMPRS LWR LEG","29581","CPT","20000107","CDM","761","RC","","Facility","Outpatient","","","363","290.40","363.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","188.76","52","","","Percent of Total Billed Charges","neg_dollar:$188.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","363.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","188.76","52","","","Percent of Total Billed Charges","neg_dollar:$188.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","188.76","52","","","Percent of Total Billed Charges","neg_dollar:$188.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","188.76","52","","","Percent of Total Billed Charges","neg_dollar:$188.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","312.18","86","","","Percent of Total Billed Charges","neg_dollar:$312.18","254.10","70","","","Percent of Total Billed Charges","neg_dollar:$254.10","188.76","52","","","Percent of Total Billed Charges","neg_dollar:$188.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","213.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$213.26;102% of Medicaid interim rate","272.25","75","","","Percent of Total Billed Charges","neg_dollar:$272.25","312.18","86","","","Percent of Total Billed Charges","neg_dollar:$312.18","254.10","70","","","Percent of Total Billed Charges","neg_dollar:$254.10","206.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$206.90;103.5% of Medicaid interim rate","363.00","150","","","Percent of Total Billed Charges","neg_dollar:$561.21;150% of Medicaid interim rate","290.40","80","","","Percent of Total Billed Charges","neg_dollar:$290.40;Percent of Total Billed Charges","333.96","92","","","Percent of Total Billed Charges","neg_dollar:$333.96","188.76","52","","","Percent of Total Billed Charges","neg_dollar:$188.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","188.76","52","","","Percent of Total Billed Charges","neg_dollar:$188.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","188.00","363.00",""
"APPLY MULTLAY COMPRS LWR LEG BILAT","29581","CPT","20000169","CDM","761","RC","50","Facility","Outpatient","","","497","397.60","497.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","258.44","52","","","Percent of Total Billed Charges","neg_dollar:$258.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","497.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","258.44","52","","","Percent of Total Billed Charges","neg_dollar:$258.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","258.44","52","","","Percent of Total Billed Charges","neg_dollar:$258.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","258.44","52","","","Percent of Total Billed Charges","neg_dollar:$258.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","427.42","86","","","Percent of Total Billed Charges","neg_dollar:$427.42","347.90","70","","","Percent of Total Billed Charges","neg_dollar:$347.90","258.44","52","","","Percent of Total Billed Charges","neg_dollar:$258.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","291.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$291.98;102% of Medicaid interim rate","372.75","75","","","Percent of Total Billed Charges","neg_dollar:$372.75","427.42","86","","","Percent of Total Billed Charges","neg_dollar:$427.42","347.90","70","","","Percent of Total Billed Charges","neg_dollar:$347.90","283.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$283.28;103.5% of Medicaid interim rate","497.00","150","","","Percent of Total Billed Charges","neg_dollar:$768.38;150% of Medicaid interim rate","397.60","80","","","Percent of Total Billed Charges","neg_dollar:$397.60;Percent of Total Billed Charges","457.24","92","","","Percent of Total Billed Charges","neg_dollar:$457.24","258.44","52","","","Percent of Total Billed Charges","neg_dollar:$258.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","258.44","52","","","Percent of Total Billed Charges","neg_dollar:$258.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","258.00","497.00",""
"APPLY MULTLAY COMPRS ARM/HAND","29584","CPT","20000340","CDM","761","RC","","Facility","Outpatient","","","335","268.00","335.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","174.20","52","","","Percent of Total Billed Charges","neg_dollar:$174.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","335.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","174.20","52","","","Percent of Total Billed Charges","neg_dollar:$174.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","174.20","52","","","Percent of Total Billed Charges","neg_dollar:$174.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","174.20","52","","","Percent of Total Billed Charges","neg_dollar:$174.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","288.10","86","","","Percent of Total Billed Charges","neg_dollar:$288.10","234.49","70","","","Percent of Total Billed Charges","neg_dollar:$234.49","174.20","52","","","Percent of Total Billed Charges","neg_dollar:$174.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","196.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$196.81;102% of Medicaid interim rate","251.25","75","","","Percent of Total Billed Charges","neg_dollar:$251.25","288.10","86","","","Percent of Total Billed Charges","neg_dollar:$288.10","234.49","70","","","Percent of Total Billed Charges","neg_dollar:$234.49","190.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$190.95;103.5% of Medicaid interim rate","335.00","150","","","Percent of Total Billed Charges","neg_dollar:$517.92;150% of Medicaid interim rate","268.00","80","","","Percent of Total Billed Charges","neg_dollar:$268;Percent of Total Billed Charges","308.20","92","","","Percent of Total Billed Charges","neg_dollar:$308.20","174.20","52","","","Percent of Total Billed Charges","neg_dollar:$174.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","174.20","52","","","Percent of Total Billed Charges","neg_dollar:$174.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","174.00","335.00",""
"ARTHROSCOPY BICEPS TENODESIS","29828","CPT","20000524","CDM","360","RC","","Facility","Outpatient","","","4158","3326.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2162.16","52","","","Percent of Total Billed Charges","neg_dollar:$2162.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2162.16","52","","","Percent of Total Billed Charges","neg_dollar:$2162.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","2162.16","52","","","Percent of Total Billed Charges","neg_dollar:$2162.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","2162.16","52","","","Percent of Total Billed Charges","neg_dollar:$2162.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","3575.88","86","","","Percent of Total Billed Charges","neg_dollar:$3575.88","2910.60","70","","","Percent of Total Billed Charges","neg_dollar:$2910.60","2162.16","52","","","Percent of Total Billed Charges","neg_dollar:$2162.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","2442.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$2442.82;102% of Medicaid interim rate","3118.50","75","","","Percent of Total Billed Charges","neg_dollar:$3118.50","3575.88","86","","","Percent of Total Billed Charges","neg_dollar:$3575.88","2910.60","70","","","Percent of Total Billed Charges","neg_dollar:$2910.60","2370.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$2370.06;103.5% of Medicaid interim rate","4158.00","150","","","Percent of Total Billed Charges","neg_dollar:$6428.47;150% of Medicaid interim rate","3326.40","80","","","Percent of Total Billed Charges","neg_dollar:$3326.40;Percent of Total Billed Charges","3825.36","92","","","Percent of Total Billed Charges","neg_dollar:$3825.36","2162.16","52","","","Percent of Total Billed Charges","neg_dollar:$2162.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","2162.16","52","","","Percent of Total Billed Charges","neg_dollar:$2162.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4158.00",""
"ARTHROSCOPY WRIST; W RLS TRNSV CARP LIG","29848","CPT","20000525","CDM","360","RC","","Facility","Outpatient","","","1477","1181.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","768.04","52","","","Percent of Total Billed Charges","neg_dollar:$768.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","768.04","52","","","Percent of Total Billed Charges","neg_dollar:$768.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","768.04","52","","","Percent of Total Billed Charges","neg_dollar:$768.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","768.04","52","","","Percent of Total Billed Charges","neg_dollar:$768.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1270.22","86","","","Percent of Total Billed Charges","neg_dollar:$1270.22","1033.89","70","","","Percent of Total Billed Charges","neg_dollar:$1033.89","768.04","52","","","Percent of Total Billed Charges","neg_dollar:$768.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","867.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$867.73;102% of Medicaid interim rate","1107.75","75","","","Percent of Total Billed Charges","neg_dollar:$1107.75","1270.22","86","","","Percent of Total Billed Charges","neg_dollar:$1270.22","1033.89","70","","","Percent of Total Billed Charges","neg_dollar:$1033.89","841.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$841.88;103.5% of Medicaid interim rate","1477.00","150","","","Percent of Total Billed Charges","neg_dollar:$2283.51;150% of Medicaid interim rate","1181.60","80","","","Percent of Total Billed Charges","neg_dollar:$1181.60;Percent of Total Billed Charges","1358.84","92","","","Percent of Total Billed Charges","neg_dollar:$1358.84","768.04","52","","","Percent of Total Billed Charges","neg_dollar:$768.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","768.04","52","","","Percent of Total Billed Charges","neg_dollar:$768.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1477.00",""
"KNEE ARTHROSCOPY/SURGERY","29880","CPT","20000529","CDM","360","RC","","Facility","Outpatient","","","4322","3457.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2247.44","52","","","Percent of Total Billed Charges","neg_dollar:$2247.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2247.44","52","","","Percent of Total Billed Charges","neg_dollar:$2247.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","2247.44","52","","","Percent of Total Billed Charges","neg_dollar:$2247.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","2247.44","52","","","Percent of Total Billed Charges","neg_dollar:$2247.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","3716.92","86","","","Percent of Total Billed Charges","neg_dollar:$3716.92","3025.39","70","","","Percent of Total Billed Charges","neg_dollar:$3025.39","2247.44","52","","","Percent of Total Billed Charges","neg_dollar:$2247.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","2539.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$2539.17;102% of Medicaid interim rate","3241.50","75","","","Percent of Total Billed Charges","neg_dollar:$3241.50","3716.92","86","","","Percent of Total Billed Charges","neg_dollar:$3716.92","3025.39","70","","","Percent of Total Billed Charges","neg_dollar:$3025.39","2463.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$2463.54;103.5% of Medicaid interim rate","4322.00","150","","","Percent of Total Billed Charges","neg_dollar:$6682.02;150% of Medicaid interim rate","3457.60","80","","","Percent of Total Billed Charges","neg_dollar:$3457.60;Percent of Total Billed Charges","3976.24","92","","","Percent of Total Billed Charges","neg_dollar:$3976.24","2247.44","52","","","Percent of Total Billed Charges","neg_dollar:$2247.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","2247.44","52","","","Percent of Total Billed Charges","neg_dollar:$2247.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4322.00",""
"KNEE ARTHROSCOPY/SURGERY","29881","CPT","20000391","CDM","360","RC","","Facility","Outpatient","","","3615","2892.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1879.80","52","","","Percent of Total Billed Charges","neg_dollar:$1879.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1879.80","52","","","Percent of Total Billed Charges","neg_dollar:$1879.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1879.80","52","","","Percent of Total Billed Charges","neg_dollar:$1879.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1879.80","52","","","Percent of Total Billed Charges","neg_dollar:$1879.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","3108.90","86","","","Percent of Total Billed Charges","neg_dollar:$3108.90","2530.50","70","","","Percent of Total Billed Charges","neg_dollar:$2530.50","1879.80","52","","","Percent of Total Billed Charges","neg_dollar:$1879.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","2123.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$2123.80;102% of Medicaid interim rate","2711.25","75","","","Percent of Total Billed Charges","neg_dollar:$2711.25","3108.90","86","","","Percent of Total Billed Charges","neg_dollar:$3108.90","2530.50","70","","","Percent of Total Billed Charges","neg_dollar:$2530.50","2060.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$2060.54;103.5% of Medicaid interim rate","3615.00","150","","","Percent of Total Billed Charges","neg_dollar:$5588.97;150% of Medicaid interim rate","2892.00","80","","","Percent of Total Billed Charges","neg_dollar:$2892;Percent of Total Billed Charges","3325.80","92","","","Percent of Total Billed Charges","neg_dollar:$3325.80","1879.80","52","","","Percent of Total Billed Charges","neg_dollar:$1879.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1879.80","52","","","Percent of Total Billed Charges","neg_dollar:$1879.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3615.00",""
"ARTHROSC KNEE W MEN REP-MED&LAT","29882","CPT","20000601","CDM","360","RC","","Facility","Outpatient","","","3158","2526.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1642.16","52","","","Percent of Total Billed Charges","neg_dollar:$1642.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1642.16","52","","","Percent of Total Billed Charges","neg_dollar:$1642.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1642.16","52","","","Percent of Total Billed Charges","neg_dollar:$1642.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1642.16","52","","","Percent of Total Billed Charges","neg_dollar:$1642.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","2715.88","86","","","Percent of Total Billed Charges","neg_dollar:$2715.88","2210.60","70","","","Percent of Total Billed Charges","neg_dollar:$2210.60","1642.16","52","","","Percent of Total Billed Charges","neg_dollar:$1642.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","1855.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$1855.32;102% of Medicaid interim rate","2368.50","75","","","Percent of Total Billed Charges","neg_dollar:$2368.50","2715.88","86","","","Percent of Total Billed Charges","neg_dollar:$2715.88","2210.60","70","","","Percent of Total Billed Charges","neg_dollar:$2210.60","1800.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$1800.06;103.5% of Medicaid interim rate","3158.00","150","","","Percent of Total Billed Charges","neg_dollar:$4882.42;150% of Medicaid interim rate","2526.40","80","","","Percent of Total Billed Charges","neg_dollar:$2526.40;Percent of Total Billed Charges","2905.36","92","","","Percent of Total Billed Charges","neg_dollar:$2905.36","1642.16","52","","","Percent of Total Billed Charges","neg_dollar:$1642.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","1642.16","52","","","Percent of Total Billed Charges","neg_dollar:$1642.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3158.00",""
"ARTHROSC KNEE; W MEN REPAIR-MED/LAT","29883","CPT","20000669","CDM","360","RC","","Facility","Outpatient","","","2448","1958.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1272.96","52","","","Percent of Total Billed Charges","neg_dollar:$1272.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1272.96","52","","","Percent of Total Billed Charges","neg_dollar:$1272.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1272.96","52","","","Percent of Total Billed Charges","neg_dollar:$1272.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1272.96","52","","","Percent of Total Billed Charges","neg_dollar:$1272.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","2105.27","86","","","Percent of Total Billed Charges","neg_dollar:$2105.27","1713.60","70","","","Percent of Total Billed Charges","neg_dollar:$1713.60","1272.96","52","","","Percent of Total Billed Charges","neg_dollar:$1272.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","1438.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1438.19;102% of Medicaid interim rate","1836.00","75","","","Percent of Total Billed Charges","neg_dollar:$1836","2105.27","86","","","Percent of Total Billed Charges","neg_dollar:$2105.27","1713.60","70","","","Percent of Total Billed Charges","neg_dollar:$1713.60","1395.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$1395.36;103.5% of Medicaid interim rate","2448.00","150","","","Percent of Total Billed Charges","neg_dollar:$3784.73;150% of Medicaid interim rate","1958.40","80","","","Percent of Total Billed Charges","neg_dollar:$1958.40;Percent of Total Billed Charges","2252.16","92","","","Percent of Total Billed Charges","neg_dollar:$2252.16","1272.96","52","","","Percent of Total Billed Charges","neg_dollar:$1272.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","1272.96","52","","","Percent of Total Billed Charges","neg_dollar:$1272.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2448.00",""
"REM FB INTRANASAL","30300","CPT","30000001","CDM","360","RC","","Facility","Outpatient","","","143","114.40","143.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","143.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","122.98","86","","","Percent of Total Billed Charges","neg_dollar:$122.98","100.10","70","","","Percent of Total Billed Charges","neg_dollar:$100.10","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","84.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$84.01;102% of Medicaid interim rate","107.25","75","","","Percent of Total Billed Charges","neg_dollar:$107.25","122.98","86","","","Percent of Total Billed Charges","neg_dollar:$122.98","100.10","70","","","Percent of Total Billed Charges","neg_dollar:$100.10","81.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$81.50;103.5% of Medicaid interim rate","143.00","150","","","Percent of Total Billed Charges","neg_dollar:$221.08;150% of Medicaid interim rate","114.40","80","","","Percent of Total Billed Charges","neg_dollar:$114.40;Percent of Total Billed Charges","131.56","92","","","Percent of Total Billed Charges","neg_dollar:$131.56","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","74.00","143.00",""
"REM FB NTRANASAL W ANESTH","30310","CPT","30000470","CDM","360","RC","","Facility","Outpatient","","","355","284.00","355.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","355.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","208.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$208.56;102% of Medicaid interim rate","266.25","75","","","Percent of Total Billed Charges","neg_dollar:$266.25","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","202.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$202.35;103.5% of Medicaid interim rate","355.00","150","","","Percent of Total Billed Charges","neg_dollar:$548.84;150% of Medicaid interim rate","284.00","80","","","Percent of Total Billed Charges","neg_dollar:$284;Percent of Total Billed Charges","326.60","92","","","Percent of Total Billed Charges","neg_dollar:$326.60","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.00","355.00",""
"CONTROL NASAL HEMORRH ANT SMPL","30901","CPT","30000002","CDM","761","RC","","Facility","Outpatient","","","387","309.60","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","227.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$227.36;102% of Medicaid interim rate","290.25","75","","","Percent of Total Billed Charges","neg_dollar:$290.25","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","220.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$220.58;103.5% of Medicaid interim rate","387.00","150","","","Percent of Total Billed Charges","neg_dollar:$598.32;150% of Medicaid interim rate","309.60","80","","","Percent of Total Billed Charges","neg_dollar:$309.60;Percent of Total Billed Charges","356.04","92","","","Percent of Total Billed Charges","neg_dollar:$356.04","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.00","387.00",""
"CNTRL POST EPISTAX INIT","30905","CPT","30000004","CDM","360","RC","","Facility","Outpatient","","","387","309.60","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","227.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$227.36;102% of Medicaid interim rate","290.25","75","","","Percent of Total Billed Charges","neg_dollar:$290.25","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","220.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$220.58;103.5% of Medicaid interim rate","387.00","150","","","Percent of Total Billed Charges","neg_dollar:$598.32;150% of Medicaid interim rate","309.60","80","","","Percent of Total Billed Charges","neg_dollar:$309.60;Percent of Total Billed Charges","356.04","92","","","Percent of Total Billed Charges","neg_dollar:$356.04","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.00","387.00",""
"INTUBATION ET EMERGENT","31500","CPT","30000078","CDM","761","RC","","Facility","Outpatient","","","355","284.00","355.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","355.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","208.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$208.56;102% of Medicaid interim rate","266.25","75","","","Percent of Total Billed Charges","neg_dollar:$266.25","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","202.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$202.35;103.5% of Medicaid interim rate","355.00","150","","","Percent of Total Billed Charges","neg_dollar:$548.84;150% of Medicaid interim rate","284.00","80","","","Percent of Total Billed Charges","neg_dollar:$284;Percent of Total Billed Charges","326.60","92","","","Percent of Total Billed Charges","neg_dollar:$326.60","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.00","355.00",""
"CATHETER ASPIRATION NASOTRACHEAL","31720","CPT","30000008","CDM","761","RC","","Facility","Outpatient","","","180","144.00","180.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","180.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.80","86","","","Percent of Total Billed Charges","neg_dollar:$154.80","125.99","70","","","Percent of Total Billed Charges","neg_dollar:$125.99","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","105.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$105.74;102% of Medicaid interim rate","135.00","75","","","Percent of Total Billed Charges","neg_dollar:$135","154.80","86","","","Percent of Total Billed Charges","neg_dollar:$154.80","125.99","70","","","Percent of Total Billed Charges","neg_dollar:$125.99","102.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$102.60;103.5% of Medicaid interim rate","180.00","150","","","Percent of Total Billed Charges","neg_dollar:$278.28;150% of Medicaid interim rate","144.00","80","","","Percent of Total Billed Charges","neg_dollar:$144;Percent of Total Billed Charges","165.60","92","","","Percent of Total Billed Charges","neg_dollar:$165.60","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","93.00","180.00",""
"INSERTION OF CHEST TUBE","32551","CPT","30000011","CDM","761","RC","","Facility","Outpatient","","","1013","810.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","526.76","52","","","Percent of Total Billed Charges","neg_dollar:$526.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","526.76","52","","","Percent of Total Billed Charges","neg_dollar:$526.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","526.76","52","","","Percent of Total Billed Charges","neg_dollar:$526.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","526.76","52","","","Percent of Total Billed Charges","neg_dollar:$526.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","871.18","86","","","Percent of Total Billed Charges","neg_dollar:$871.18","709.09","70","","","Percent of Total Billed Charges","neg_dollar:$709.09","526.76","52","","","Percent of Total Billed Charges","neg_dollar:$526.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","595.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$595.13;102% of Medicaid interim rate","759.75","75","","","Percent of Total Billed Charges","neg_dollar:$759.75","871.18","86","","","Percent of Total Billed Charges","neg_dollar:$871.18","709.09","70","","","Percent of Total Billed Charges","neg_dollar:$709.09","577.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$577.41;103.5% of Medicaid interim rate","1013.00","150","","","Percent of Total Billed Charges","neg_dollar:$1566.14;150% of Medicaid interim rate","810.40","80","","","Percent of Total Billed Charges","neg_dollar:$810.40;Percent of Total Billed Charges","931.96","92","","","Percent of Total Billed Charges","neg_dollar:$931.96","526.76","52","","","Percent of Total Billed Charges","neg_dollar:$526.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","526.76","52","","","Percent of Total Billed Charges","neg_dollar:$526.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","526.00","1013.00",""
"ASPIRATE PLEURA W/ IMAGING","32555","CPT","30000293","CDM","761","RC","","Facility","Outpatient","","","1735","1388.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","902.20","52","","","Percent of Total Billed Charges","neg_dollar:$902.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","902.20","52","","","Percent of Total Billed Charges","neg_dollar:$902.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","902.20","52","","","Percent of Total Billed Charges","neg_dollar:$902.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","902.20","52","","","Percent of Total Billed Charges","neg_dollar:$902.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","1492.10","86","","","Percent of Total Billed Charges","neg_dollar:$1492.10","1214.50","70","","","Percent of Total Billed Charges","neg_dollar:$1214.50","902.20","52","","","Percent of Total Billed Charges","neg_dollar:$902.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","1019.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$1019.31;102% of Medicaid interim rate","1301.25","75","","","Percent of Total Billed Charges","neg_dollar:$1301.25","1492.10","86","","","Percent of Total Billed Charges","neg_dollar:$1492.10","1214.50","70","","","Percent of Total Billed Charges","neg_dollar:$1214.50","988.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$988.94;103.5% of Medicaid interim rate","1735.00","150","","","Percent of Total Billed Charges","neg_dollar:$2682.39;150% of Medicaid interim rate","1388.00","80","","","Percent of Total Billed Charges","neg_dollar:$1388;Percent of Total Billed Charges","1596.20","92","","","Percent of Total Billed Charges","neg_dollar:$1596.20","902.20","52","","","Percent of Total Billed Charges","neg_dollar:$902.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","902.20","52","","","Percent of Total Billed Charges","neg_dollar:$902.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1735.00",""
"VENIPUNCTURE AGE 3 YRS/>","36410","CPT","30000127","CDM","761","RC","","Facility","Outpatient","","","339","271.20","339.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","176.28","52","","","Percent of Total Billed Charges","neg_dollar:$176.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","339.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","176.28","52","","","Percent of Total Billed Charges","neg_dollar:$176.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","176.28","52","","","Percent of Total Billed Charges","neg_dollar:$176.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","176.28","52","","","Percent of Total Billed Charges","neg_dollar:$176.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","291.54","86","","","Percent of Total Billed Charges","neg_dollar:$291.54","237.29","70","","","Percent of Total Billed Charges","neg_dollar:$237.29","176.28","52","","","Percent of Total Billed Charges","neg_dollar:$176.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","199.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$199.16;102% of Medicaid interim rate","254.25","75","","","Percent of Total Billed Charges","neg_dollar:$254.25","291.54","86","","","Percent of Total Billed Charges","neg_dollar:$291.54","237.29","70","","","Percent of Total Billed Charges","neg_dollar:$237.29","193.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$193.23;103.5% of Medicaid interim rate","339.00","150","","","Percent of Total Billed Charges","neg_dollar:$524.11;150% of Medicaid interim rate","271.20","80","","","Percent of Total Billed Charges","neg_dollar:$271.20;Percent of Total Billed Charges","311.88","92","","","Percent of Total Billed Charges","neg_dollar:$311.88","176.28","52","","","Percent of Total Billed Charges","neg_dollar:$176.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","176.28","52","","","Percent of Total Billed Charges","neg_dollar:$176.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","176.00","339.00",""
"ROUTINE VENIPUNCTURE","36415","CPT","30000091","CDM","300","RC","","Facility","Outpatient","","","28","22.40","28.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","28.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.08","86","","","Percent of Total Billed Charges","neg_dollar:$24.08","19.59","70","","","Percent of Total Billed Charges","neg_dollar:$19.59","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.44;102% of Medicaid interim rate","21.00","75","","","Percent of Total Billed Charges","neg_dollar:$21","24.08","86","","","Percent of Total Billed Charges","neg_dollar:$24.08","19.59","70","","","Percent of Total Billed Charges","neg_dollar:$19.59","15.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.95;103.5% of Medicaid interim rate","28.00","150","","","Percent of Total Billed Charges","neg_dollar:$43.28;150% of Medicaid interim rate","22.40","80","","","Percent of Total Billed Charges","neg_dollar:$22.40;Percent of Total Billed Charges","","","","21.00","Fee Schedule","","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.00","28.00",""
"CAPILLARY BLOOD DRAW","36416","CPT","30000092","CDM","300","RC","","Facility","Outpatient","","","28","22.40","28.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","28.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.08","86","","","Percent of Total Billed Charges","neg_dollar:$24.08","19.59","70","","","Percent of Total Billed Charges","neg_dollar:$19.59","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.44;102% of Medicaid interim rate","21.00","75","","","Percent of Total Billed Charges","neg_dollar:$21","24.08","86","","","Percent of Total Billed Charges","neg_dollar:$24.08","19.59","70","","","Percent of Total Billed Charges","neg_dollar:$19.59","15.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.95;103.5% of Medicaid interim rate","28.00","150","","","Percent of Total Billed Charges","neg_dollar:$43.28;150% of Medicaid interim rate","22.40","80","","","Percent of Total Billed Charges","neg_dollar:$22.40;Percent of Total Billed Charges","","","","22.00","Fee Schedule","","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.00","28.00",""
"TRANSFUSION BLOOD OR COMPONENT PER UNIT","36430","CPT","30000599","CDM","391","RC","","Facility","Outpatient","","","1051","840.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","546.52","52","","","Percent of Total Billed Charges","neg_dollar:$546.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","546.52","52","","","Percent of Total Billed Charges","neg_dollar:$546.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","546.52","52","","","Percent of Total Billed Charges","neg_dollar:$546.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","546.52","52","","","Percent of Total Billed Charges","neg_dollar:$546.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","903.86","86","","","Percent of Total Billed Charges","neg_dollar:$903.86","735.69","70","","","Percent of Total Billed Charges","neg_dollar:$735.69","546.52","52","","","Percent of Total Billed Charges","neg_dollar:$546.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","617.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$617.46;102% of Medicaid interim rate","788.25","75","","","Percent of Total Billed Charges","neg_dollar:$788.25","903.86","86","","","Percent of Total Billed Charges","neg_dollar:$903.86","735.69","70","","","Percent of Total Billed Charges","neg_dollar:$735.69","599.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$599.06;103.5% of Medicaid interim rate","1051.00","150","","","Percent of Total Billed Charges","neg_dollar:$1624.89;150% of Medicaid interim rate","840.80","80","","","Percent of Total Billed Charges","neg_dollar:$840.80;Percent of Total Billed Charges","966.92","92","","","Percent of Total Billed Charges","neg_dollar:$966.92","546.52","52","","","Percent of Total Billed Charges","neg_dollar:$546.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","546.52","52","","","Percent of Total Billed Charges","neg_dollar:$546.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","546.00","1051.00",""
"INS NON-TUNNEL CV CATH 5 YRS/>","36556","CPT","30000054","CDM","761","RC","","Facility","Outpatient","","","580","464.00","580.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","580.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","498.80","86","","","Percent of Total Billed Charges","neg_dollar:$498.80","406.00","70","","","Percent of Total Billed Charges","neg_dollar:$406","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","340.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$340.74;102% of Medicaid interim rate","435.00","75","","","Percent of Total Billed Charges","neg_dollar:$435","498.80","86","","","Percent of Total Billed Charges","neg_dollar:$498.80","406.00","70","","","Percent of Total Billed Charges","neg_dollar:$406","330.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$330.59;103.5% of Medicaid interim rate","580.00","150","","","Percent of Total Billed Charges","neg_dollar:$896.70;150% of Medicaid interim rate","464.00","80","","","Percent of Total Billed Charges","neg_dollar:$464;Percent of Total Billed Charges","533.60","92","","","Percent of Total Billed Charges","neg_dollar:$533.60","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","301.00","580.00",""
"INS PICC AGE WO IMG 5 YRS/>","36569","CPT","30000093","CDM","761","RC","","Facility","Outpatient","","","1465","1172.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","761.80","52","","","Percent of Total Billed Charges","neg_dollar:$761.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","761.80","52","","","Percent of Total Billed Charges","neg_dollar:$761.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","761.80","52","","","Percent of Total Billed Charges","neg_dollar:$761.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","761.80","52","","","Percent of Total Billed Charges","neg_dollar:$761.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1259.90","86","","","Percent of Total Billed Charges","neg_dollar:$1259.90","1025.50","70","","","Percent of Total Billed Charges","neg_dollar:$1025.50","761.80","52","","","Percent of Total Billed Charges","neg_dollar:$761.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","860.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$860.68;102% of Medicaid interim rate","1098.75","75","","","Percent of Total Billed Charges","neg_dollar:$1098.75","1259.90","86","","","Percent of Total Billed Charges","neg_dollar:$1259.90","1025.50","70","","","Percent of Total Billed Charges","neg_dollar:$1025.50","835.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$835.05;103.5% of Medicaid interim rate","1465.00","150","","","Percent of Total Billed Charges","neg_dollar:$2264.96;150% of Medicaid interim rate","1172.00","80","","","Percent of Total Billed Charges","neg_dollar:$1172;Percent of Total Billed Charges","1347.80","92","","","Percent of Total Billed Charges","neg_dollar:$1347.80","761.80","52","","","Percent of Total Billed Charges","neg_dollar:$761.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","761.80","52","","","Percent of Total Billed Charges","neg_dollar:$761.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1465.00",""
"DRAW BLOOD OFF VENOUS DEVICE","36591","CPT","30000055","CDM","300","RC","","Facility","Outpatient","","","131","104.80","131.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","131.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","112.66","86","","","Percent of Total Billed Charges","neg_dollar:$112.66","91.69","70","","","Percent of Total Billed Charges","neg_dollar:$91.69","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","76.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$76.96;102% of Medicaid interim rate","98.25","75","","","Percent of Total Billed Charges","neg_dollar:$98.25","112.66","86","","","Percent of Total Billed Charges","neg_dollar:$112.66","91.69","70","","","Percent of Total Billed Charges","neg_dollar:$91.69","74.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$74.66;103.5% of Medicaid interim rate","131.00","150","","","Percent of Total Billed Charges","neg_dollar:$202.53;150% of Medicaid interim rate","104.80","80","","","Percent of Total Billed Charges","neg_dollar:$104.80;Percent of Total Billed Charges","","","","92.00","Fee Schedule","","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","68.00","131.00",""
"COLLECT BLOOD FROM PICC","36592","CPT","30000056","CDM","300","RC","","Facility","Outpatient","","","78","62.40","78.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","40.56","52","","","Percent of Total Billed Charges","neg_dollar:$40.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","78.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","40.56","52","","","Percent of Total Billed Charges","neg_dollar:$40.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","40.56","52","","","Percent of Total Billed Charges","neg_dollar:$40.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","40.56","52","","","Percent of Total Billed Charges","neg_dollar:$40.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","67.08","86","","","Percent of Total Billed Charges","neg_dollar:$67.08","54.59","70","","","Percent of Total Billed Charges","neg_dollar:$54.59","40.56","52","","","Percent of Total Billed Charges","neg_dollar:$40.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","45.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$45.82;102% of Medicaid interim rate","58.50","75","","","Percent of Total Billed Charges","neg_dollar:$58.50","67.08","86","","","Percent of Total Billed Charges","neg_dollar:$67.08","54.59","70","","","Percent of Total Billed Charges","neg_dollar:$54.59","44.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$44.45;103.5% of Medicaid interim rate","78.00","150","","","Percent of Total Billed Charges","neg_dollar:$120.59;150% of Medicaid interim rate","62.40","80","","","Percent of Total Billed Charges","neg_dollar:$62.40;Percent of Total Billed Charges","","","","54.00","Fee Schedule","","40.56","52","","","Percent of Total Billed Charges","neg_dollar:$40.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","40.56","52","","","Percent of Total Billed Charges","neg_dollar:$40.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","40.00","78.00",""
"DECLOT VASCULAR DEVICE","36593","CPT","30000097","CDM","360","RC","","Facility","Outpatient","","","330","264.00","330.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","171.60","52","","","Percent of Total Billed Charges","neg_dollar:$171.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","330.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","171.60","52","","","Percent of Total Billed Charges","neg_dollar:$171.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","171.60","52","","","Percent of Total Billed Charges","neg_dollar:$171.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","171.60","52","","","Percent of Total Billed Charges","neg_dollar:$171.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","283.80","86","","","Percent of Total Billed Charges","neg_dollar:$283.80","230.99","70","","","Percent of Total Billed Charges","neg_dollar:$230.99","171.60","52","","","Percent of Total Billed Charges","neg_dollar:$171.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","193.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$193.87;102% of Medicaid interim rate","247.50","75","","","Percent of Total Billed Charges","neg_dollar:$247.50","283.80","86","","","Percent of Total Billed Charges","neg_dollar:$283.80","230.99","70","","","Percent of Total Billed Charges","neg_dollar:$230.99","188.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$188.10;103.5% of Medicaid interim rate","330.00","150","","","Percent of Total Billed Charges","neg_dollar:$510.19;150% of Medicaid interim rate","264.00","80","","","Percent of Total Billed Charges","neg_dollar:$264;Percent of Total Billed Charges","303.60","92","","","Percent of Total Billed Charges","neg_dollar:$303.60","171.60","52","","","Percent of Total Billed Charges","neg_dollar:$171.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","171.60","52","","","Percent of Total Billed Charges","neg_dollar:$171.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","171.00","330.00",""
"ARTERIAL PUNCTURE BLOOD FOR DX","36600","CPT","30000084","CDM","761","RC","","Facility","Outpatient","","","142","113.60","142.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","73.84","52","","","Percent of Total Billed Charges","neg_dollar:$73.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","142.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","73.84","52","","","Percent of Total Billed Charges","neg_dollar:$73.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","73.84","52","","","Percent of Total Billed Charges","neg_dollar:$73.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","73.84","52","","","Percent of Total Billed Charges","neg_dollar:$73.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","122.12","86","","","Percent of Total Billed Charges","neg_dollar:$122.12","99.39","70","","","Percent of Total Billed Charges","neg_dollar:$99.39","73.84","52","","","Percent of Total Billed Charges","neg_dollar:$73.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","83.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$83.42;102% of Medicaid interim rate","106.50","75","","","Percent of Total Billed Charges","neg_dollar:$106.50","122.12","86","","","Percent of Total Billed Charges","neg_dollar:$122.12","99.39","70","","","Percent of Total Billed Charges","neg_dollar:$99.39","80.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$80.94;103.5% of Medicaid interim rate","142.00","150","","","Percent of Total Billed Charges","neg_dollar:$219.53;150% of Medicaid interim rate","113.60","80","","","Percent of Total Billed Charges","neg_dollar:$113.60;Percent of Total Billed Charges","130.64","92","","","Percent of Total Billed Charges","neg_dollar:$130.64","73.84","52","","","Percent of Total Billed Charges","neg_dollar:$73.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","73.84","52","","","Percent of Total Billed Charges","neg_dollar:$73.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","73.00","142.00",""
"PLACE NEEDLE INTRAOSSEOUS INFUSION","36680","CPT","30000057","CDM","450","RC","","Facility","Outpatient","","","414","331.20","414.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","414.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","356.04","86","","","Percent of Total Billed Charges","neg_dollar:$356.04","289.79","70","","","Percent of Total Billed Charges","neg_dollar:$289.79","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","243.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$243.22;102% of Medicaid interim rate","310.50","75","","","Percent of Total Billed Charges","neg_dollar:$310.50","356.04","86","","","Percent of Total Billed Charges","neg_dollar:$356.04","289.79","70","","","Percent of Total Billed Charges","neg_dollar:$289.79","235.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$235.98;103.5% of Medicaid interim rate","414.00","150","","","Percent of Total Billed Charges","neg_dollar:$640.06;150% of Medicaid interim rate","331.20","80","","","Percent of Total Billed Charges","neg_dollar:$331.20;Percent of Total Billed Charges","380.88","92","","","Percent of Total Billed Charges","neg_dollar:$380.88","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","215.00","414.00",""
"INJ RA TRACER ID SENTINEL NODE","38792","CPT","30000168","CDM","360","RC","","Facility","Outpatient","","","704","563.20","704.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","704.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","605.43","86","","","Percent of Total Billed Charges","neg_dollar:$605.43","492.79","70","","","Percent of Total Billed Charges","neg_dollar:$492.79","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","413.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$413.59;102% of Medicaid interim rate","528.00","75","","","Percent of Total Billed Charges","neg_dollar:$528","605.43","86","","","Percent of Total Billed Charges","neg_dollar:$605.43","492.79","70","","","Percent of Total Billed Charges","neg_dollar:$492.79","401.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$401.28;103.5% of Medicaid interim rate","704.00","150","","","Percent of Total Billed Charges","neg_dollar:$1088.41;150% of Medicaid interim rate","563.20","80","","","Percent of Total Billed Charges","neg_dollar:$563.20;Percent of Total Billed Charges","647.68","92","","","Percent of Total Billed Charges","neg_dollar:$647.68","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.00","704.00",""
"REP LAC 2.5CM/< FLR MOUTH/ANT 2/3","41250","CPT","40000004","CDM","450","RC","","Facility","Outpatient","","","407","325.60","407.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","407.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","350.02","86","","","Percent of Total Billed Charges","neg_dollar:$350.02","284.90","70","","","Percent of Total Billed Charges","neg_dollar:$284.90","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","239.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$239.11;102% of Medicaid interim rate","305.25","75","","","Percent of Total Billed Charges","neg_dollar:$305.25","350.02","86","","","Percent of Total Billed Charges","neg_dollar:$350.02","284.90","70","","","Percent of Total Billed Charges","neg_dollar:$284.90","231.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$231.98;103.5% of Medicaid interim rate","407.00","150","","","Percent of Total Billed Charges","neg_dollar:$629.24;150% of Medicaid interim rate","325.60","80","","","Percent of Total Billed Charges","neg_dollar:$325.60;Percent of Total Billed Charges","374.44","92","","","Percent of Total Billed Charges","neg_dollar:$374.44","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","211.00","407.00",""
"REP LAC TONGUE FLR MOUTH > 2.6 CPLX","41252","CPT","40000049","CDM","450","RC","","Facility","Outpatient","","","1469","1175.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","763.88","52","","","Percent of Total Billed Charges","neg_dollar:$763.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","763.88","52","","","Percent of Total Billed Charges","neg_dollar:$763.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","763.88","52","","","Percent of Total Billed Charges","neg_dollar:$763.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","763.88","52","","","Percent of Total Billed Charges","neg_dollar:$763.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1263.34","86","","","Percent of Total Billed Charges","neg_dollar:$1263.34","1028.30","70","","","Percent of Total Billed Charges","neg_dollar:$1028.30","763.88","52","","","Percent of Total Billed Charges","neg_dollar:$763.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","863.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$863.03;102% of Medicaid interim rate","1101.75","75","","","Percent of Total Billed Charges","neg_dollar:$1101.75","1263.34","86","","","Percent of Total Billed Charges","neg_dollar:$1263.34","1028.30","70","","","Percent of Total Billed Charges","neg_dollar:$1028.30","837.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$837.32;103.5% of Medicaid interim rate","1469.00","150","","","Percent of Total Billed Charges","neg_dollar:$2271.14;150% of Medicaid interim rate","1175.20","80","","","Percent of Total Billed Charges","neg_dollar:$1175.20;Percent of Total Billed Charges","1351.48","92","","","Percent of Total Billed Charges","neg_dollar:$1351.48","763.88","52","","","Percent of Total Billed Charges","neg_dollar:$763.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","763.88","52","","","Percent of Total Billed Charges","neg_dollar:$763.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1469.00",""
"DR ABSC CYST HEMATOM DENTOALVEOLAR","41800","CPT","40000005","CDM","450","RC","","Facility","Outpatient","","","385","308.00","385.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","200.20","52","","","Percent of Total Billed Charges","neg_dollar:$200.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","385.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","200.20","52","","","Percent of Total Billed Charges","neg_dollar:$200.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","200.20","52","","","Percent of Total Billed Charges","neg_dollar:$200.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","200.20","52","","","Percent of Total Billed Charges","neg_dollar:$200.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","331.10","86","","","Percent of Total Billed Charges","neg_dollar:$331.10","269.50","70","","","Percent of Total Billed Charges","neg_dollar:$269.50","200.20","52","","","Percent of Total Billed Charges","neg_dollar:$200.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","226.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$226.18;102% of Medicaid interim rate","288.75","75","","","Percent of Total Billed Charges","neg_dollar:$288.75","331.10","86","","","Percent of Total Billed Charges","neg_dollar:$331.10","269.50","70","","","Percent of Total Billed Charges","neg_dollar:$269.50","219.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$219.45;103.5% of Medicaid interim rate","385.00","150","","","Percent of Total Billed Charges","neg_dollar:$595.22;150% of Medicaid interim rate","308.00","80","","","Percent of Total Billed Charges","neg_dollar:$308;Percent of Total Billed Charges","354.20","92","","","Percent of Total Billed Charges","neg_dollar:$354.20","200.20","52","","","Percent of Total Billed Charges","neg_dollar:$200.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","200.20","52","","","Percent of Total Billed Charges","neg_dollar:$200.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","200.00","385.00",""
"RPLC GTUBE NO REVISN TRC","43762","CPT","40000397","CDM","761","RC","","Facility","Outpatient","","","733","586.40","733.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","733.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","630.38","86","","","Percent of Total Billed Charges","neg_dollar:$630.38","513.10","70","","","Percent of Total Billed Charges","neg_dollar:$513.10","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","430.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$430.63;102% of Medicaid interim rate","549.75","75","","","Percent of Total Billed Charges","neg_dollar:$549.75","630.38","86","","","Percent of Total Billed Charges","neg_dollar:$630.38","513.10","70","","","Percent of Total Billed Charges","neg_dollar:$513.10","417.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$417.80;103.5% of Medicaid interim rate","733.00","150","","","Percent of Total Billed Charges","neg_dollar:$1133.25;150% of Medicaid interim rate","586.40","80","","","Percent of Total Billed Charges","neg_dollar:$586.40;Percent of Total Billed Charges","674.36","92","","","Percent of Total Billed Charges","neg_dollar:$674.36","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","381.00","733.00",""
"I&D PERIANAL ABSCESS","46050","CPT","40000011","CDM","360","RC","","Facility","Outpatient","","","1047","837.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","544.44","52","","","Percent of Total Billed Charges","neg_dollar:$544.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","544.44","52","","","Percent of Total Billed Charges","neg_dollar:$544.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","544.44","52","","","Percent of Total Billed Charges","neg_dollar:$544.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","544.44","52","","","Percent of Total Billed Charges","neg_dollar:$544.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","900.42","86","","","Percent of Total Billed Charges","neg_dollar:$900.42","732.90","70","","","Percent of Total Billed Charges","neg_dollar:$732.90","544.44","52","","","Percent of Total Billed Charges","neg_dollar:$544.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","615.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$615.11;102% of Medicaid interim rate","785.25","75","","","Percent of Total Billed Charges","neg_dollar:$785.25","900.42","86","","","Percent of Total Billed Charges","neg_dollar:$900.42","732.90","70","","","Percent of Total Billed Charges","neg_dollar:$732.90","596.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$596.79;103.5% of Medicaid interim rate","1047.00","150","","","Percent of Total Billed Charges","neg_dollar:$1618.71;150% of Medicaid interim rate","837.60","80","","","Percent of Total Billed Charges","neg_dollar:$837.60;Percent of Total Billed Charges","963.24","92","","","Percent of Total Billed Charges","neg_dollar:$963.24","544.44","52","","","Percent of Total Billed Charges","neg_dollar:$544.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","544.44","52","","","Percent of Total Billed Charges","neg_dollar:$544.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","544.00","1047.00",""
"INCISE THROMBOSED HEMORRHOID EXT","46083","CPT","40000012","CDM","360","RC","","Facility","Outpatient","","","521","416.80","521.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","521.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","448.06","86","","","Percent of Total Billed Charges","neg_dollar:$448.06","364.70","70","","","Percent of Total Billed Charges","neg_dollar:$364.70","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","306.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$306.08;102% of Medicaid interim rate","390.75","75","","","Percent of Total Billed Charges","neg_dollar:$390.75","448.06","86","","","Percent of Total Billed Charges","neg_dollar:$448.06","364.70","70","","","Percent of Total Billed Charges","neg_dollar:$364.70","296.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$296.96;103.5% of Medicaid interim rate","521.00","150","","","Percent of Total Billed Charges","neg_dollar:$805.49;150% of Medicaid interim rate","416.80","80","","","Percent of Total Billed Charges","neg_dollar:$416.80;Percent of Total Billed Charges","479.32","92","","","Percent of Total Billed Charges","neg_dollar:$479.32","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","270.00","521.00",""
"LIGATION OF HEMORRHOID(S)","46221","CPT","40000309","CDM","360","RC","","Facility","Outpatient","","","967","773.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","502.84","52","","","Percent of Total Billed Charges","neg_dollar:$502.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","502.84","52","","","Percent of Total Billed Charges","neg_dollar:$502.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","502.84","52","","","Percent of Total Billed Charges","neg_dollar:$502.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","502.84","52","","","Percent of Total Billed Charges","neg_dollar:$502.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","831.62","86","","","Percent of Total Billed Charges","neg_dollar:$831.62","676.90","70","","","Percent of Total Billed Charges","neg_dollar:$676.90","502.84","52","","","Percent of Total Billed Charges","neg_dollar:$502.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","568.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$568.11;102% of Medicaid interim rate","725.25","75","","","Percent of Total Billed Charges","neg_dollar:$725.25","831.62","86","","","Percent of Total Billed Charges","neg_dollar:$831.62","676.90","70","","","Percent of Total Billed Charges","neg_dollar:$676.90","551.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$551.18;103.5% of Medicaid interim rate","967.00","150","","","Percent of Total Billed Charges","neg_dollar:$1495.03;150% of Medicaid interim rate","773.60","80","","","Percent of Total Billed Charges","neg_dollar:$773.60;Percent of Total Billed Charges","889.64","92","","","Percent of Total Billed Charges","neg_dollar:$889.64","502.84","52","","","Percent of Total Billed Charges","neg_dollar:$502.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","502.84","52","","","Percent of Total Billed Charges","neg_dollar:$502.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","502.00","967.00",""
"ABD PARACENTESIS W/IMAGING","49083","CPT","40000146","CDM","360","RC","","Facility","Outpatient","","","890","712.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","462.80","52","","","Percent of Total Billed Charges","neg_dollar:$462.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","462.80","52","","","Percent of Total Billed Charges","neg_dollar:$462.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","462.80","52","","","Percent of Total Billed Charges","neg_dollar:$462.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","462.80","52","","","Percent of Total Billed Charges","neg_dollar:$462.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","765.40","86","","","Percent of Total Billed Charges","neg_dollar:$765.40","623.00","70","","","Percent of Total Billed Charges","neg_dollar:$623","462.80","52","","","Percent of Total Billed Charges","neg_dollar:$462.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","522.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$522.87;102% of Medicaid interim rate","667.50","75","","","Percent of Total Billed Charges","neg_dollar:$667.50","765.40","86","","","Percent of Total Billed Charges","neg_dollar:$765.40","623.00","70","","","Percent of Total Billed Charges","neg_dollar:$623","507.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$507.29;103.5% of Medicaid interim rate","890.00","150","","","Percent of Total Billed Charges","neg_dollar:$1375.98;150% of Medicaid interim rate","712.00","80","","","Percent of Total Billed Charges","neg_dollar:$712;Percent of Total Billed Charges","818.80","92","","","Percent of Total Billed Charges","neg_dollar:$818.80","462.80","52","","","Percent of Total Billed Charges","neg_dollar:$462.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","462.80","52","","","Percent of Total Billed Charges","neg_dollar:$462.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","462.00","890.00",""
"IMAGE CATH FLUID COLL VISCERAL","49405","CPT","40000197","CDM","360","RC","","Facility","Outpatient","","","1696","1356.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1458.56","86","","","Percent of Total Billed Charges","neg_dollar:$1458.56","1187.19","70","","","Percent of Total Billed Charges","neg_dollar:$1187.19","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","996.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$996.39;102% of Medicaid interim rate","1272.00","75","","","Percent of Total Billed Charges","neg_dollar:$1272","1458.56","86","","","Percent of Total Billed Charges","neg_dollar:$1458.56","1187.19","70","","","Percent of Total Billed Charges","neg_dollar:$1187.19","966.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$966.71;103.5% of Medicaid interim rate","1696.00","150","","","Percent of Total Billed Charges","neg_dollar:$2622.10;150% of Medicaid interim rate","1356.80","80","","","Percent of Total Billed Charges","neg_dollar:$1356.80;Percent of Total Billed Charges","1560.32","92","","","Percent of Total Billed Charges","neg_dollar:$1560.32","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1696.00",""
"IMAGE CATH FLUID COLL PERI/RETRO","49406","CPT","40000198","CDM","360","RC","","Facility","Outpatient","","","1696","1356.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1458.56","86","","","Percent of Total Billed Charges","neg_dollar:$1458.56","1187.19","70","","","Percent of Total Billed Charges","neg_dollar:$1187.19","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","996.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$996.39;102% of Medicaid interim rate","1272.00","75","","","Percent of Total Billed Charges","neg_dollar:$1272","1458.56","86","","","Percent of Total Billed Charges","neg_dollar:$1458.56","1187.19","70","","","Percent of Total Billed Charges","neg_dollar:$1187.19","966.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$966.71;103.5% of Medicaid interim rate","1696.00","150","","","Percent of Total Billed Charges","neg_dollar:$2622.10;150% of Medicaid interim rate","1356.80","80","","","Percent of Total Billed Charges","neg_dollar:$1356.80;Percent of Total Billed Charges","1560.32","92","","","Percent of Total Billed Charges","neg_dollar:$1560.32","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1696.00",""
"IMAGE CATH FLUID COLL TRANSVAG/RECTAL","49407","CPT","40000199","CDM","360","RC","","Facility","Outpatient","","","1696","1356.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1458.56","86","","","Percent of Total Billed Charges","neg_dollar:$1458.56","1187.19","70","","","Percent of Total Billed Charges","neg_dollar:$1187.19","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","996.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$996.39;102% of Medicaid interim rate","1272.00","75","","","Percent of Total Billed Charges","neg_dollar:$1272","1458.56","86","","","Percent of Total Billed Charges","neg_dollar:$1458.56","1187.19","70","","","Percent of Total Billed Charges","neg_dollar:$1187.19","966.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$966.71;103.5% of Medicaid interim rate","1696.00","150","","","Percent of Total Billed Charges","neg_dollar:$2622.10;150% of Medicaid interim rate","1356.80","80","","","Percent of Total Billed Charges","neg_dollar:$1356.80;Percent of Total Billed Charges","1560.32","92","","","Percent of Total Billed Charges","neg_dollar:$1560.32","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1696.00",""
"PLACE GASTROSTOMY TUBE PERC","49440","CPT","40000057","CDM","360","RC","","Facility","Outpatient","","","2207","1765.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1147.64","52","","","Percent of Total Billed Charges","neg_dollar:$1147.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1147.64","52","","","Percent of Total Billed Charges","neg_dollar:$1147.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1147.64","52","","","Percent of Total Billed Charges","neg_dollar:$1147.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1147.64","52","","","Percent of Total Billed Charges","neg_dollar:$1147.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1898.02","86","","","Percent of Total Billed Charges","neg_dollar:$1898.02","1544.89","70","","","Percent of Total Billed Charges","neg_dollar:$1544.89","1147.64","52","","","Percent of Total Billed Charges","neg_dollar:$1147.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","1296.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$1296.61;102% of Medicaid interim rate","1655.25","75","","","Percent of Total Billed Charges","neg_dollar:$1655.25","1898.02","86","","","Percent of Total Billed Charges","neg_dollar:$1898.02","1544.89","70","","","Percent of Total Billed Charges","neg_dollar:$1544.89","1257.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$1257.98;103.5% of Medicaid interim rate","2207.00","150","","","Percent of Total Billed Charges","neg_dollar:$3412.13;150% of Medicaid interim rate","1765.60","80","","","Percent of Total Billed Charges","neg_dollar:$1765.60;Percent of Total Billed Charges","2030.44","92","","","Percent of Total Billed Charges","neg_dollar:$2030.44","1147.64","52","","","Percent of Total Billed Charges","neg_dollar:$1147.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","1147.64","52","","","Percent of Total Billed Charges","neg_dollar:$1147.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2207.00",""
"ASP INJ RENAL CYST/PELVIS PERC","50390","CPT","50000036","CDM","360","RC","","Facility","Outpatient","","","1554","1243.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","808.08","52","","","Percent of Total Billed Charges","neg_dollar:$808.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","808.08","52","","","Percent of Total Billed Charges","neg_dollar:$808.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","808.08","52","","","Percent of Total Billed Charges","neg_dollar:$808.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","808.08","52","","","Percent of Total Billed Charges","neg_dollar:$808.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","1336.44","86","","","Percent of Total Billed Charges","neg_dollar:$1336.44","1087.80","70","","","Percent of Total Billed Charges","neg_dollar:$1087.80","808.08","52","","","Percent of Total Billed Charges","neg_dollar:$808.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","912.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$912.97;102% of Medicaid interim rate","1165.50","75","","","Percent of Total Billed Charges","neg_dollar:$1165.50","1336.44","86","","","Percent of Total Billed Charges","neg_dollar:$1336.44","1087.80","70","","","Percent of Total Billed Charges","neg_dollar:$1087.80","885.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$885.78;103.5% of Medicaid interim rate","1554.00","150","","","Percent of Total Billed Charges","neg_dollar:$2402.56;150% of Medicaid interim rate","1243.20","80","","","Percent of Total Billed Charges","neg_dollar:$1243.20;Percent of Total Billed Charges","1429.68","92","","","Percent of Total Billed Charges","neg_dollar:$1429.68","808.08","52","","","Percent of Total Billed Charges","neg_dollar:$808.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","808.08","52","","","Percent of Total Billed Charges","neg_dollar:$808.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1554.00",""
"SMPL BLADDER IRRIGATE LAVAGE/INSTILL","51700","CPT","50000004","CDM","761","RC","","Facility","Outpatient","","","572","457.60","572.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","297.44","52","","","Percent of Total Billed Charges","neg_dollar:$297.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","572.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","297.44","52","","","Percent of Total Billed Charges","neg_dollar:$297.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","297.44","52","","","Percent of Total Billed Charges","neg_dollar:$297.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","297.44","52","","","Percent of Total Billed Charges","neg_dollar:$297.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","491.92","86","","","Percent of Total Billed Charges","neg_dollar:$491.92","400.40","70","","","Percent of Total Billed Charges","neg_dollar:$400.40","297.44","52","","","Percent of Total Billed Charges","neg_dollar:$297.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","336.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$336.04;102% of Medicaid interim rate","429.00","75","","","Percent of Total Billed Charges","neg_dollar:$429","491.92","86","","","Percent of Total Billed Charges","neg_dollar:$491.92","400.40","70","","","Percent of Total Billed Charges","neg_dollar:$400.40","326.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$326.03;103.5% of Medicaid interim rate","572.00","150","","","Percent of Total Billed Charges","neg_dollar:$884.34;150% of Medicaid interim rate","457.60","80","","","Percent of Total Billed Charges","neg_dollar:$457.60;Percent of Total Billed Charges","526.24","92","","","Percent of Total Billed Charges","neg_dollar:$526.24","297.44","52","","","Percent of Total Billed Charges","neg_dollar:$297.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","297.44","52","","","Percent of Total Billed Charges","neg_dollar:$297.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","297.00","572.00",""
"INSERT BLADDER CATHETER","51701","CPT","50000005","CDM","761","RC","","Facility","Outpatient","","","284","227.20","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","166.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$166.84;102% of Medicaid interim rate","213.00","75","","","Percent of Total Billed Charges","neg_dollar:$213","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","161.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$161.88;103.5% of Medicaid interim rate","284.00","150","","","Percent of Total Billed Charges","neg_dollar:$439.07;150% of Medicaid interim rate","227.20","80","","","Percent of Total Billed Charges","neg_dollar:$227.20;Percent of Total Billed Charges","261.28","92","","","Percent of Total Billed Charges","neg_dollar:$261.28","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.00","284.00",""
"INSERT TEMP BLADDER CATH","51702","CPT","50000006","CDM","761","RC","","Facility","Outpatient","","","284","227.20","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","166.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$166.84;102% of Medicaid interim rate","213.00","75","","","Percent of Total Billed Charges","neg_dollar:$213","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","161.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$161.88;103.5% of Medicaid interim rate","284.00","150","","","Percent of Total Billed Charges","neg_dollar:$439.07;150% of Medicaid interim rate","227.20","80","","","Percent of Total Billed Charges","neg_dollar:$227.20;Percent of Total Billed Charges","261.28","92","","","Percent of Total Billed Charges","neg_dollar:$261.28","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.00","284.00",""
"CHANGE OF CYSTOSTOMY TUBE SIMPLE","51705","CPT","50000007","CDM","360","RC","","Facility","Outpatient","","","373","298.40","373.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","193.96","52","","","Percent of Total Billed Charges","neg_dollar:$193.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","373.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","193.96","52","","","Percent of Total Billed Charges","neg_dollar:$193.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","193.96","52","","","Percent of Total Billed Charges","neg_dollar:$193.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","193.96","52","","","Percent of Total Billed Charges","neg_dollar:$193.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","320.78","86","","","Percent of Total Billed Charges","neg_dollar:$320.78","261.09","70","","","Percent of Total Billed Charges","neg_dollar:$261.09","193.96","52","","","Percent of Total Billed Charges","neg_dollar:$193.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","219.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$219.13;102% of Medicaid interim rate","279.75","75","","","Percent of Total Billed Charges","neg_dollar:$279.75","320.78","86","","","Percent of Total Billed Charges","neg_dollar:$320.78","261.09","70","","","Percent of Total Billed Charges","neg_dollar:$261.09","212.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$212.60;103.5% of Medicaid interim rate","373.00","150","","","Percent of Total Billed Charges","neg_dollar:$576.67;150% of Medicaid interim rate","298.40","80","","","Percent of Total Billed Charges","neg_dollar:$298.40;Percent of Total Billed Charges","343.16","92","","","Percent of Total Billed Charges","neg_dollar:$343.16","193.96","52","","","Percent of Total Billed Charges","neg_dollar:$193.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","193.96","52","","","Percent of Total Billed Charges","neg_dollar:$193.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","193.00","373.00",""
"US PV RESIDUAL URINE","51798","CPT","50000008","CDM","761","RC","","Facility","Outpatient","","","84","67.20","84.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","43.68","52","","","Percent of Total Billed Charges","neg_dollar:$43.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","84.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","43.68","52","","","Percent of Total Billed Charges","neg_dollar:$43.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","43.68","52","","","Percent of Total Billed Charges","neg_dollar:$43.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","43.68","52","","","Percent of Total Billed Charges","neg_dollar:$43.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","72.24","86","","","Percent of Total Billed Charges","neg_dollar:$72.24","58.80","70","","","Percent of Total Billed Charges","neg_dollar:$58.80","43.68","52","","","Percent of Total Billed Charges","neg_dollar:$43.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","49.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$49.34;102% of Medicaid interim rate","63.00","75","","","Percent of Total Billed Charges","neg_dollar:$63","72.24","86","","","Percent of Total Billed Charges","neg_dollar:$72.24","58.80","70","","","Percent of Total Billed Charges","neg_dollar:$58.80","47.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$47.87;103.5% of Medicaid interim rate","84.00","150","","","Percent of Total Billed Charges","neg_dollar:$129.86;150% of Medicaid interim rate","67.20","80","","","Percent of Total Billed Charges","neg_dollar:$67.20;Percent of Total Billed Charges","77.28","92","","","Percent of Total Billed Charges","neg_dollar:$77.28","43.68","52","","","Percent of Total Billed Charges","neg_dollar:$43.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","43.68","52","","","Percent of Total Billed Charges","neg_dollar:$43.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","43.00","84.00",""
"I & D OF VULVA OR PERINEAL ABSCESS","56405","CPT","50000009","CDM","450","RC","","Facility","Outpatient","","","437","349.60","437.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","437.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","375.82","86","","","Percent of Total Billed Charges","neg_dollar:$375.82","305.90","70","","","Percent of Total Billed Charges","neg_dollar:$305.90","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","256.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$256.73;102% of Medicaid interim rate","327.75","75","","","Percent of Total Billed Charges","neg_dollar:$327.75","375.82","86","","","Percent of Total Billed Charges","neg_dollar:$375.82","305.90","70","","","Percent of Total Billed Charges","neg_dollar:$305.90","249.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.08;103.5% of Medicaid interim rate","437.00","150","","","Percent of Total Billed Charges","neg_dollar:$675.62;150% of Medicaid interim rate","349.60","80","","","Percent of Total Billed Charges","neg_dollar:$349.60;Percent of Total Billed Charges","402.04","92","","","Percent of Total Billed Charges","neg_dollar:$402.04","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","227.00","437.00",""
"I & D OF BARTHOLINS GLAND ABSCESS","56420","CPT","50000010","CDM","360","RC","","Facility","Outpatient","","","355","284.00","355.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","355.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","208.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$208.56;102% of Medicaid interim rate","266.25","75","","","Percent of Total Billed Charges","neg_dollar:$266.25","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","202.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$202.35;103.5% of Medicaid interim rate","355.00","150","","","Percent of Total Billed Charges","neg_dollar:$548.84;150% of Medicaid interim rate","284.00","80","","","Percent of Total Billed Charges","neg_dollar:$284;Percent of Total Billed Charges","326.60","92","","","Percent of Total Billed Charges","neg_dollar:$326.60","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.60","52","","","Percent of Total Billed Charges","neg_dollar:$184.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","184.00","355.00",""
"REMOVE IUD","58301","CPT","50000012","CDM","450","RC","","Facility","Outpatient","","","607","485.60","607.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","315.64","52","","","Percent of Total Billed Charges","neg_dollar:$315.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","607.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","315.64","52","","","Percent of Total Billed Charges","neg_dollar:$315.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","315.64","52","","","Percent of Total Billed Charges","neg_dollar:$315.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","315.64","52","","","Percent of Total Billed Charges","neg_dollar:$315.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","522.02","86","","","Percent of Total Billed Charges","neg_dollar:$522.02","424.90","70","","","Percent of Total Billed Charges","neg_dollar:$424.90","315.64","52","","","Percent of Total Billed Charges","neg_dollar:$315.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","356.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$356.61;102% of Medicaid interim rate","455.25","75","","","Percent of Total Billed Charges","neg_dollar:$455.25","522.02","86","","","Percent of Total Billed Charges","neg_dollar:$522.02","424.90","70","","","Percent of Total Billed Charges","neg_dollar:$424.90","345.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$345.98;103.5% of Medicaid interim rate","607.00","150","","","Percent of Total Billed Charges","neg_dollar:$938.45;150% of Medicaid interim rate","485.60","80","","","Percent of Total Billed Charges","neg_dollar:$485.60;Percent of Total Billed Charges","558.44","92","","","Percent of Total Billed Charges","neg_dollar:$558.44","315.64","52","","","Percent of Total Billed Charges","neg_dollar:$315.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","315.64","52","","","Percent of Total Billed Charges","neg_dollar:$315.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","315.00","607.00",""
"INJ SALINE HYSTEROGRAM","58340","CPT","50000056","CDM","360","RC","","Facility","Outpatient","","","386","308.80","386.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","200.72","52","","","Percent of Total Billed Charges","neg_dollar:$200.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","386.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","200.72","52","","","Percent of Total Billed Charges","neg_dollar:$200.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","200.72","52","","","Percent of Total Billed Charges","neg_dollar:$200.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","200.72","52","","","Percent of Total Billed Charges","neg_dollar:$200.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","331.96","86","","","Percent of Total Billed Charges","neg_dollar:$331.96","270.20","70","","","Percent of Total Billed Charges","neg_dollar:$270.20","200.72","52","","","Percent of Total Billed Charges","neg_dollar:$200.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","226.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$226.77;102% of Medicaid interim rate","289.50","75","","","Percent of Total Billed Charges","neg_dollar:$289.50","331.96","86","","","Percent of Total Billed Charges","neg_dollar:$331.96","270.20","70","","","Percent of Total Billed Charges","neg_dollar:$270.20","220.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$220.01;103.5% of Medicaid interim rate","386.00","150","","","Percent of Total Billed Charges","neg_dollar:$596.77;150% of Medicaid interim rate","308.80","80","","","Percent of Total Billed Charges","neg_dollar:$308.80;Percent of Total Billed Charges","355.12","92","","","Percent of Total Billed Charges","neg_dollar:$355.12","200.72","52","","","Percent of Total Billed Charges","neg_dollar:$200.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","200.72","52","","","Percent of Total Billed Charges","neg_dollar:$200.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","200.00","386.00",""
"FETAL CONTRACTION STRESS TEST","59020","CPT","50000063","CDM","720","RC","","Facility","Outpatient","","","580","464.00","580.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","580.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","498.80","86","","","Percent of Total Billed Charges","neg_dollar:$498.80","406.00","70","","","Percent of Total Billed Charges","neg_dollar:$406","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","340.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$340.74;102% of Medicaid interim rate","435.00","75","","","Percent of Total Billed Charges","neg_dollar:$435","498.80","86","","","Percent of Total Billed Charges","neg_dollar:$498.80","406.00","70","","","Percent of Total Billed Charges","neg_dollar:$406","330.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$330.59;103.5% of Medicaid interim rate","580.00","150","","","Percent of Total Billed Charges","neg_dollar:$896.70;150% of Medicaid interim rate","464.00","80","","","Percent of Total Billed Charges","neg_dollar:$464;Percent of Total Billed Charges","533.60","92","","","Percent of Total Billed Charges","neg_dollar:$533.60","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","301.00","580.00",""
"FETAL NON-STRESS TEST","59025","CPT","50000064","CDM","720","RC","","Facility","Outpatient","","","519","415.20","519.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","519.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","446.34","86","","","Percent of Total Billed Charges","neg_dollar:$446.34","363.29","70","","","Percent of Total Billed Charges","neg_dollar:$363.29","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","304.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$304.91;102% of Medicaid interim rate","389.25","75","","","Percent of Total Billed Charges","neg_dollar:$389.25","446.34","86","","","Percent of Total Billed Charges","neg_dollar:$446.34","363.29","70","","","Percent of Total Billed Charges","neg_dollar:$363.29","295.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$295.83;103.5% of Medicaid interim rate","519.00","150","","","Percent of Total Billed Charges","neg_dollar:$802.39;150% of Medicaid interim rate","415.20","80","","","Percent of Total Billed Charges","neg_dollar:$415.20;Percent of Total Billed Charges","477.48","92","","","Percent of Total Billed Charges","neg_dollar:$477.48","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","269.00","519.00",""
"EPISIOTOMY OR VAGINAL REPAIR","59300","CPT","50000076","CDM","450","RC","","Facility","Outpatient","","","537","429.60","537.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","537.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","461.82","86","","","Percent of Total Billed Charges","neg_dollar:$461.82","375.90","70","","","Percent of Total Billed Charges","neg_dollar:$375.90","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","315.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$315.48;102% of Medicaid interim rate","402.75","75","","","Percent of Total Billed Charges","neg_dollar:$402.75","461.82","86","","","Percent of Total Billed Charges","neg_dollar:$461.82","375.90","70","","","Percent of Total Billed Charges","neg_dollar:$375.90","306.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$306.09;103.5% of Medicaid interim rate","537.00","150","","","Percent of Total Billed Charges","neg_dollar:$830.22;150% of Medicaid interim rate","429.60","80","","","Percent of Total Billed Charges","neg_dollar:$429.60;Percent of Total Billed Charges","494.04","92","","","Percent of Total Billed Charges","neg_dollar:$494.04","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.00","537.00",""
"VAGINAL DELIVERY ONLY","59409","CPT","50000013","CDM","450","RC","","Facility","Outpatient","","","1827","1461.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","950.04","52","","","Percent of Total Billed Charges","neg_dollar:$950.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","950.04","52","","","Percent of Total Billed Charges","neg_dollar:$950.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","950.04","52","","","Percent of Total Billed Charges","neg_dollar:$950.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","950.04","52","","","Percent of Total Billed Charges","neg_dollar:$950.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1571.22","86","","","Percent of Total Billed Charges","neg_dollar:$1571.22","1278.89","70","","","Percent of Total Billed Charges","neg_dollar:$1278.89","950.04","52","","","Percent of Total Billed Charges","neg_dollar:$950.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1073.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$1073.36;102% of Medicaid interim rate","1370.25","75","","","Percent of Total Billed Charges","neg_dollar:$1370.25","1571.22","86","","","Percent of Total Billed Charges","neg_dollar:$1571.22","1278.89","70","","","Percent of Total Billed Charges","neg_dollar:$1278.89","1041.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$1041.38;103.5% of Medicaid interim rate","1827.00","150","","","Percent of Total Billed Charges","neg_dollar:$2824.63;150% of Medicaid interim rate","1461.60","80","","","Percent of Total Billed Charges","neg_dollar:$1461.60;Percent of Total Billed Charges","1680.84","92","","","Percent of Total Billed Charges","neg_dollar:$1680.84","950.04","52","","","Percent of Total Billed Charges","neg_dollar:$950.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","950.04","52","","","Percent of Total Billed Charges","neg_dollar:$950.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1827.00",""
"SPINAL PUNCTURE LUMBAR DIAG","62270","CPT","60000037","CDM","761","RC","","Facility","Outpatient","","","1106","884.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","951.16","86","","","Percent of Total Billed Charges","neg_dollar:$951.16","774.19","70","","","Percent of Total Billed Charges","neg_dollar:$774.19","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","649.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$649.77;102% of Medicaid interim rate","829.50","75","","","Percent of Total Billed Charges","neg_dollar:$829.50","951.16","86","","","Percent of Total Billed Charges","neg_dollar:$951.16","774.19","70","","","Percent of Total Billed Charges","neg_dollar:$774.19","630.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$630.42;103.5% of Medicaid interim rate","1106.00","150","","","Percent of Total Billed Charges","neg_dollar:$1709.93;150% of Medicaid interim rate","884.80","80","","","Percent of Total Billed Charges","neg_dollar:$884.80;Percent of Total Billed Charges","1017.52","92","","","Percent of Total Billed Charges","neg_dollar:$1017.52","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","575.00","1106.00",""
"SPINAL PUNCTURE DRAIN CSF","62272","CPT","60000085","CDM","360","RC","","Facility","Outpatient","","","914","731.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","475.28","52","","","Percent of Total Billed Charges","neg_dollar:$475.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","475.28","52","","","Percent of Total Billed Charges","neg_dollar:$475.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","475.28","52","","","Percent of Total Billed Charges","neg_dollar:$475.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","475.28","52","","","Percent of Total Billed Charges","neg_dollar:$475.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","786.04","86","","","Percent of Total Billed Charges","neg_dollar:$786.04","639.80","70","","","Percent of Total Billed Charges","neg_dollar:$639.80","475.28","52","","","Percent of Total Billed Charges","neg_dollar:$475.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","536.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$536.97;102% of Medicaid interim rate","685.50","75","","","Percent of Total Billed Charges","neg_dollar:$685.50","786.04","86","","","Percent of Total Billed Charges","neg_dollar:$786.04","639.80","70","","","Percent of Total Billed Charges","neg_dollar:$639.80","520.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$520.97;103.5% of Medicaid interim rate","914.00","150","","","Percent of Total Billed Charges","neg_dollar:$1413.08;150% of Medicaid interim rate","731.20","80","","","Percent of Total Billed Charges","neg_dollar:$731.20;Percent of Total Billed Charges","840.88","92","","","Percent of Total Billed Charges","neg_dollar:$840.88","475.28","52","","","Percent of Total Billed Charges","neg_dollar:$475.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","475.28","52","","","Percent of Total Billed Charges","neg_dollar:$475.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","475.00","914.00",""
"INJ EPIDURAL BLOOD OR CLOT PATCH","62273","CPT","60000038","CDM","761","RC","","Facility","Outpatient","","","1525","1220.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","793.00","52","","","Percent of Total Billed Charges","neg_dollar:$793;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","793.00","52","","","Percent of Total Billed Charges","neg_dollar:$793;102% Medicare Outpatient Cost to Charge Ratio of 52%","793.00","52","","","Percent of Total Billed Charges","neg_dollar:$793;102% Medicare Outpatient Cost to Charge Ratio of 52%","793.00","52","","","Percent of Total Billed Charges","neg_dollar:$793;102% Medicare Outpatient Cost to Charge Ratio of 52%","1311.50","86","","","Percent of Total Billed Charges","neg_dollar:$1311.50","1067.50","70","","","Percent of Total Billed Charges","neg_dollar:$1067.50","793.00","52","","","Percent of Total Billed Charges","neg_dollar:$793;105% Medicare Outpatient Cost to Charge Ratio of 52%","895.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$895.93;102% of Medicaid interim rate","1143.75","75","","","Percent of Total Billed Charges","neg_dollar:$1143.75","1311.50","86","","","Percent of Total Billed Charges","neg_dollar:$1311.50","1067.50","70","","","Percent of Total Billed Charges","neg_dollar:$1067.50","869.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$869.24;103.5% of Medicaid interim rate","1525.00","150","","","Percent of Total Billed Charges","neg_dollar:$2357.72;150% of Medicaid interim rate","1220.00","80","","","Percent of Total Billed Charges","neg_dollar:$1220;Percent of Total Billed Charges","1403.00","92","","","Percent of Total Billed Charges","neg_dollar:$1403","793.00","52","","","Percent of Total Billed Charges","neg_dollar:$793;100% Medicare Outpatient Cost to Charge Ratio of 52%","793.00","52","","","Percent of Total Billed Charges","neg_dollar:$793;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1525.00",""
"INJ NEUROLYTIC EPIDURAL LUMB/CAUDAL","62282","CPT","60000146","CDM","360","RC","","Facility","Outpatient","","","2301","1840.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1978.86","86","","","Percent of Total Billed Charges","neg_dollar:$1978.86","1610.69","70","","","Percent of Total Billed Charges","neg_dollar:$1610.69","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","1351.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$1351.83;102% of Medicaid interim rate","1725.75","75","","","Percent of Total Billed Charges","neg_dollar:$1725.75","1978.86","86","","","Percent of Total Billed Charges","neg_dollar:$1978.86","1610.69","70","","","Percent of Total Billed Charges","neg_dollar:$1610.69","1311.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$1311.57;103.5% of Medicaid interim rate","2301.00","150","","","Percent of Total Billed Charges","neg_dollar:$3557.46;150% of Medicaid interim rate","1840.80","80","","","Percent of Total Billed Charges","neg_dollar:$1840.80;Percent of Total Billed Charges","2116.92","92","","","Percent of Total Billed Charges","neg_dollar:$2116.92","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2301.00",""
"INJ INTERLAM C/T W IMG","62321","CPT","60000221","CDM","761","RC","","Facility","Outpatient","","","2366","1892.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","2034.76","86","","","Percent of Total Billed Charges","neg_dollar:$2034.76","1656.19","70","","","Percent of Total Billed Charges","neg_dollar:$1656.19","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","1390.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1390.02;102% of Medicaid interim rate","1774.50","75","","","Percent of Total Billed Charges","neg_dollar:$1774.50","2034.76","86","","","Percent of Total Billed Charges","neg_dollar:$2034.76","1656.19","70","","","Percent of Total Billed Charges","neg_dollar:$1656.19","1348.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$1348.62;103.5% of Medicaid interim rate","2366.00","150","","","Percent of Total Billed Charges","neg_dollar:$3657.95;150% of Medicaid interim rate","1892.80","80","","","Percent of Total Billed Charges","neg_dollar:$1892.80;Percent of Total Billed Charges","2176.72","92","","","Percent of Total Billed Charges","neg_dollar:$2176.72","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2366.00",""
"INJ INTERLAM L/S W IMG","62323","CPT","60000223","CDM","761","RC","","Facility","Outpatient","","","2366","1892.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","2034.76","86","","","Percent of Total Billed Charges","neg_dollar:$2034.76","1656.19","70","","","Percent of Total Billed Charges","neg_dollar:$1656.19","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","1390.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1390.02;102% of Medicaid interim rate","1774.50","75","","","Percent of Total Billed Charges","neg_dollar:$1774.50","2034.76","86","","","Percent of Total Billed Charges","neg_dollar:$2034.76","1656.19","70","","","Percent of Total Billed Charges","neg_dollar:$1656.19","1348.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$1348.62;103.5% of Medicaid interim rate","2366.00","150","","","Percent of Total Billed Charges","neg_dollar:$3657.95;150% of Medicaid interim rate","1892.80","80","","","Percent of Total Billed Charges","neg_dollar:$1892.80;Percent of Total Billed Charges","2176.72","92","","","Percent of Total Billed Charges","neg_dollar:$2176.72","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","1230.32","52","","","Percent of Total Billed Charges","neg_dollar:$1230.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2366.00",""
"INJ ANESTH/STER TRIGEMINAL NERVE EA BR","64400","CPT","60000039","CDM","360","RC","","Facility","Outpatient","","","743","594.40","743.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","386.36","52","","","Percent of Total Billed Charges","neg_dollar:$386.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","743.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","386.36","52","","","Percent of Total Billed Charges","neg_dollar:$386.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","386.36","52","","","Percent of Total Billed Charges","neg_dollar:$386.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","386.36","52","","","Percent of Total Billed Charges","neg_dollar:$386.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","638.98","86","","","Percent of Total Billed Charges","neg_dollar:$638.98","520.10","70","","","Percent of Total Billed Charges","neg_dollar:$520.10","386.36","52","","","Percent of Total Billed Charges","neg_dollar:$386.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","436.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$436.51;102% of Medicaid interim rate","557.25","75","","","Percent of Total Billed Charges","neg_dollar:$557.25","638.98","86","","","Percent of Total Billed Charges","neg_dollar:$638.98","520.10","70","","","Percent of Total Billed Charges","neg_dollar:$520.10","423.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$423.51;103.5% of Medicaid interim rate","743.00","150","","","Percent of Total Billed Charges","neg_dollar:$1148.71;150% of Medicaid interim rate","594.40","80","","","Percent of Total Billed Charges","neg_dollar:$594.40;Percent of Total Billed Charges","683.56","92","","","Percent of Total Billed Charges","neg_dollar:$683.56","386.36","52","","","Percent of Total Billed Charges","neg_dollar:$386.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","386.36","52","","","Percent of Total Billed Charges","neg_dollar:$386.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","386.00","743.00",""
"INJ ANESTH/STER GREATER OCCIPITAL NERVE","64405","CPT","60000040","CDM","761","RC","","Facility","Outpatient","","","1211","968.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1041.46","86","","","Percent of Total Billed Charges","neg_dollar:$1041.46","847.69","70","","","Percent of Total Billed Charges","neg_dollar:$847.69","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","711.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$711.46;102% of Medicaid interim rate","908.25","75","","","Percent of Total Billed Charges","neg_dollar:$908.25","1041.46","86","","","Percent of Total Billed Charges","neg_dollar:$1041.46","847.69","70","","","Percent of Total Billed Charges","neg_dollar:$847.69","690.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$690.27;103.5% of Medicaid interim rate","1211.00","150","","","Percent of Total Billed Charges","neg_dollar:$1872.26;150% of Medicaid interim rate","968.80","80","","","Percent of Total Billed Charges","neg_dollar:$968.80;Percent of Total Billed Charges","1114.12","92","","","Percent of Total Billed Charges","neg_dollar:$1114.12","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","629.00","1211.00",""
"INJ ANESTH GREATER OCCIP NRV PAIN BILAT","64405","CPT","60000041","CDM","761","RC","50","Facility","Outpatient","","","1818","1454.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1563.48","86","","","Percent of Total Billed Charges","neg_dollar:$1563.48","1272.60","70","","","Percent of Total Billed Charges","neg_dollar:$1272.60","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","1068.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$1068.07;102% of Medicaid interim rate","1363.50","75","","","Percent of Total Billed Charges","neg_dollar:$1363.50","1563.48","86","","","Percent of Total Billed Charges","neg_dollar:$1563.48","1272.60","70","","","Percent of Total Billed Charges","neg_dollar:$1272.60","1036.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$1036.26;103.5% of Medicaid interim rate","1818.00","150","","","Percent of Total Billed Charges","neg_dollar:$2810.71;150% of Medicaid interim rate","1454.40","80","","","Percent of Total Billed Charges","neg_dollar:$1454.40;Percent of Total Billed Charges","1672.56","92","","","Percent of Total Billed Charges","neg_dollar:$1672.56","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1818.00",""
"INJ ANESTH/STER INTERCOSTAL NERVE SGL LEV","64420","CPT","60000016","CDM","761","RC","","Facility","Outpatient","","","1211","968.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1041.46","86","","","Percent of Total Billed Charges","neg_dollar:$1041.46","847.69","70","","","Percent of Total Billed Charges","neg_dollar:$847.69","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","711.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$711.46;102% of Medicaid interim rate","908.25","75","","","Percent of Total Billed Charges","neg_dollar:$908.25","1041.46","86","","","Percent of Total Billed Charges","neg_dollar:$1041.46","847.69","70","","","Percent of Total Billed Charges","neg_dollar:$847.69","690.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$690.27;103.5% of Medicaid interim rate","1211.00","150","","","Percent of Total Billed Charges","neg_dollar:$1872.26;150% of Medicaid interim rate","968.80","80","","","Percent of Total Billed Charges","neg_dollar:$968.80;Percent of Total Billed Charges","1114.12","92","","","Percent of Total Billed Charges","neg_dollar:$1114.12","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","629.00","1211.00",""
"INJ ANESTH/STER INTERCOST NRV ADDTL LEV","64421","CPT","60000017","CDM","761","RC","","Facility","Outpatient","","","2318","1854.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1993.48","86","","","Percent of Total Billed Charges","neg_dollar:$1993.48","1622.60","70","","","Percent of Total Billed Charges","neg_dollar:$1622.60","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","1361.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1361.82;102% of Medicaid interim rate","1738.50","75","","","Percent of Total Billed Charges","neg_dollar:$1738.50","1993.48","86","","","Percent of Total Billed Charges","neg_dollar:$1993.48","1622.60","70","","","Percent of Total Billed Charges","neg_dollar:$1622.60","1321.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$1321.26;103.5% of Medicaid interim rate","2318.00","150","","","Percent of Total Billed Charges","neg_dollar:$3583.74;150% of Medicaid interim rate","1854.40","80","","","Percent of Total Billed Charges","neg_dollar:$1854.40;Percent of Total Billed Charges","2132.56","92","","","Percent of Total Billed Charges","neg_dollar:$2132.56","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2318.00",""
"INJ ANESTH/STER ILIOING/ILIOHYPOGASTRIC","64425","CPT","60000018","CDM","761","RC","","Facility","Outpatient","","","1211","968.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1041.46","86","","","Percent of Total Billed Charges","neg_dollar:$1041.46","847.69","70","","","Percent of Total Billed Charges","neg_dollar:$847.69","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","711.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$711.46;102% of Medicaid interim rate","908.25","75","","","Percent of Total Billed Charges","neg_dollar:$908.25","1041.46","86","","","Percent of Total Billed Charges","neg_dollar:$1041.46","847.69","70","","","Percent of Total Billed Charges","neg_dollar:$847.69","690.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$690.27;103.5% of Medicaid interim rate","1211.00","150","","","Percent of Total Billed Charges","neg_dollar:$1872.26;150% of Medicaid interim rate","968.80","80","","","Percent of Total Billed Charges","neg_dollar:$968.80;Percent of Total Billed Charges","1114.12","92","","","Percent of Total Billed Charges","neg_dollar:$1114.12","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","629.00","1211.00",""
"INJ ANESTH/STER ILIOING/ILIOHYPOGASTRIC","64425","CPT","60000018","CDM","761","RC","","Facility","Outpatient","","","1817","1453.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","944.84","52","","","Percent of Total Billed Charges","neg_dollar:$944.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","944.84","52","","","Percent of Total Billed Charges","neg_dollar:$944.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","944.84","52","","","Percent of Total Billed Charges","neg_dollar:$944.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","944.84","52","","","Percent of Total Billed Charges","neg_dollar:$944.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","1562.62","86","","","Percent of Total Billed Charges","neg_dollar:$1562.62","1271.89","70","","","Percent of Total Billed Charges","neg_dollar:$1271.89","944.84","52","","","Percent of Total Billed Charges","neg_dollar:$944.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","1067.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1067.48;102% of Medicaid interim rate","1362.75","75","","","Percent of Total Billed Charges","neg_dollar:$1362.75","1562.62","86","","","Percent of Total Billed Charges","neg_dollar:$1562.62","1271.89","70","","","Percent of Total Billed Charges","neg_dollar:$1271.89","1035.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$1035.68;103.5% of Medicaid interim rate","1817.00","150","","","Percent of Total Billed Charges","neg_dollar:$2809.17;150% of Medicaid interim rate","1453.60","80","","","Percent of Total Billed Charges","neg_dollar:$1453.60;Percent of Total Billed Charges","1671.64","92","","","Percent of Total Billed Charges","neg_dollar:$1671.64","944.84","52","","","Percent of Total Billed Charges","neg_dollar:$944.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","944.84","52","","","Percent of Total Billed Charges","neg_dollar:$944.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1817.00",""
"INJ ANESTH/STER SCIATIC NRV","64445","CPT","60000019","CDM","761","RC","","Facility","Outpatient","","","1211","968.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1041.46","86","","","Percent of Total Billed Charges","neg_dollar:$1041.46","847.69","70","","","Percent of Total Billed Charges","neg_dollar:$847.69","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","711.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$711.46;102% of Medicaid interim rate","908.25","75","","","Percent of Total Billed Charges","neg_dollar:$908.25","1041.46","86","","","Percent of Total Billed Charges","neg_dollar:$1041.46","847.69","70","","","Percent of Total Billed Charges","neg_dollar:$847.69","690.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$690.27;103.5% of Medicaid interim rate","1211.00","150","","","Percent of Total Billed Charges","neg_dollar:$1872.26;150% of Medicaid interim rate","968.80","80","","","Percent of Total Billed Charges","neg_dollar:$968.80;Percent of Total Billed Charges","1114.12","92","","","Percent of Total Billed Charges","neg_dollar:$1114.12","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","629.00","1211.00",""
"INJ ANESTH/STER FEMORAL NRV","64447","CPT","60000020","CDM","761","RC","","Facility","Outpatient","","","1818","1454.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1563.48","86","","","Percent of Total Billed Charges","neg_dollar:$1563.48","1272.60","70","","","Percent of Total Billed Charges","neg_dollar:$1272.60","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","1068.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$1068.07;102% of Medicaid interim rate","1363.50","75","","","Percent of Total Billed Charges","neg_dollar:$1363.50","1563.48","86","","","Percent of Total Billed Charges","neg_dollar:$1563.48","1272.60","70","","","Percent of Total Billed Charges","neg_dollar:$1272.60","1036.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$1036.26;103.5% of Medicaid interim rate","1818.00","150","","","Percent of Total Billed Charges","neg_dollar:$2810.71;150% of Medicaid interim rate","1454.40","80","","","Percent of Total Billed Charges","neg_dollar:$1454.40;Percent of Total Billed Charges","1672.56","92","","","Percent of Total Billed Charges","neg_dollar:$1672.56","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1818.00",""
"FEMORAL N BLOCK SGL BILAT","64447","CPT","60000147","CDM","761","RC","50","Facility","Outpatient","","","1818","1454.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1563.48","86","","","Percent of Total Billed Charges","neg_dollar:$1563.48","1272.60","70","","","Percent of Total Billed Charges","neg_dollar:$1272.60","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","1068.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$1068.07;102% of Medicaid interim rate","1363.50","75","","","Percent of Total Billed Charges","neg_dollar:$1363.50","1563.48","86","","","Percent of Total Billed Charges","neg_dollar:$1563.48","1272.60","70","","","Percent of Total Billed Charges","neg_dollar:$1272.60","1036.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$1036.26;103.5% of Medicaid interim rate","1818.00","150","","","Percent of Total Billed Charges","neg_dollar:$2810.71;150% of Medicaid interim rate","1454.40","80","","","Percent of Total Billed Charges","neg_dollar:$1454.40;Percent of Total Billed Charges","1672.56","92","","","Percent of Total Billed Charges","neg_dollar:$1672.56","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","945.36","52","","","Percent of Total Billed Charges","neg_dollar:$945.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1818.00",""
"INJ ANESTH/STER OTHR PERIPHERAL NRV/BRANCH","64450","CPT","60000042","CDM","360","RC","","Facility","Outpatient","","","284","227.20","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","166.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$166.84;102% of Medicaid interim rate","213.00","75","","","Percent of Total Billed Charges","neg_dollar:$213","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","161.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$161.88;103.5% of Medicaid interim rate","284.00","150","","","Percent of Total Billed Charges","neg_dollar:$439.07;150% of Medicaid interim rate","227.20","80","","","Percent of Total Billed Charges","neg_dollar:$227.20;Percent of Total Billed Charges","261.28","92","","","Percent of Total Billed Charges","neg_dollar:$261.28","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.00","284.00",""
"INJ ANESTH/STER SI JOINT NRV NRVTG","64451","CPT","60000280","CDM","761","RC","","Facility","Outpatient","","","1145","916.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","595.40","52","","","Percent of Total Billed Charges","neg_dollar:$595.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","595.40","52","","","Percent of Total Billed Charges","neg_dollar:$595.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","595.40","52","","","Percent of Total Billed Charges","neg_dollar:$595.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","595.40","52","","","Percent of Total Billed Charges","neg_dollar:$595.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","984.69","86","","","Percent of Total Billed Charges","neg_dollar:$984.69","801.50","70","","","Percent of Total Billed Charges","neg_dollar:$801.50","595.40","52","","","Percent of Total Billed Charges","neg_dollar:$595.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","672.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$672.68;102% of Medicaid interim rate","858.75","75","","","Percent of Total Billed Charges","neg_dollar:$858.75","984.69","86","","","Percent of Total Billed Charges","neg_dollar:$984.69","801.50","70","","","Percent of Total Billed Charges","neg_dollar:$801.50","652.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$652.65;103.5% of Medicaid interim rate","1145.00","150","","","Percent of Total Billed Charges","neg_dollar:$1770.22;150% of Medicaid interim rate","916.00","80","","","Percent of Total Billed Charges","neg_dollar:$916;Percent of Total Billed Charges","1053.40","92","","","Percent of Total Billed Charges","neg_dollar:$1053.40","595.40","52","","","Percent of Total Billed Charges","neg_dollar:$595.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","595.40","52","","","Percent of Total Billed Charges","neg_dollar:$595.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","595.00","1145.00",""
"INJ ANESTH/STER SI JOINT NRV NRVTG","64451","CPT","60000280","CDM","761","RC","","Facility","Outpatient","","","2140","1712.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1112.80","52","","","Percent of Total Billed Charges","neg_dollar:$1112.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1112.80","52","","","Percent of Total Billed Charges","neg_dollar:$1112.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1112.80","52","","","Percent of Total Billed Charges","neg_dollar:$1112.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1112.80","52","","","Percent of Total Billed Charges","neg_dollar:$1112.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1840.39","86","","","Percent of Total Billed Charges","neg_dollar:$1840.39","1498.00","70","","","Percent of Total Billed Charges","neg_dollar:$1498","1112.80","52","","","Percent of Total Billed Charges","neg_dollar:$1112.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","1257.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$1257.24;102% of Medicaid interim rate","1605.00","75","","","Percent of Total Billed Charges","neg_dollar:$1605","1840.39","86","","","Percent of Total Billed Charges","neg_dollar:$1840.39","1498.00","70","","","Percent of Total Billed Charges","neg_dollar:$1498","1219.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$1219.80;103.5% of Medicaid interim rate","2140.00","150","","","Percent of Total Billed Charges","neg_dollar:$3308.54;150% of Medicaid interim rate","1712.00","80","","","Percent of Total Billed Charges","neg_dollar:$1712;Percent of Total Billed Charges","1968.80","92","","","Percent of Total Billed Charges","neg_dollar:$1968.80","1112.80","52","","","Percent of Total Billed Charges","neg_dollar:$1112.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1112.80","52","","","Percent of Total Billed Charges","neg_dollar:$1112.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2140.00",""
"INJ ANESTH/STER GENICULAR NRV BRANCH","64454","CPT","60000281","CDM","761","RC","","Facility","Outpatient","","","557","445.60","557.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","289.64","52","","","Percent of Total Billed Charges","neg_dollar:$289.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","557.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","289.64","52","","","Percent of Total Billed Charges","neg_dollar:$289.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","289.64","52","","","Percent of Total Billed Charges","neg_dollar:$289.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","289.64","52","","","Percent of Total Billed Charges","neg_dollar:$289.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","479.02","86","","","Percent of Total Billed Charges","neg_dollar:$479.02","389.90","70","","","Percent of Total Billed Charges","neg_dollar:$389.90","289.64","52","","","Percent of Total Billed Charges","neg_dollar:$289.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","327.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$327.23;102% of Medicaid interim rate","417.75","75","","","Percent of Total Billed Charges","neg_dollar:$417.75","479.02","86","","","Percent of Total Billed Charges","neg_dollar:$479.02","389.90","70","","","Percent of Total Billed Charges","neg_dollar:$389.90","317.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$317.48;103.5% of Medicaid interim rate","557.00","150","","","Percent of Total Billed Charges","neg_dollar:$861.14;150% of Medicaid interim rate","445.60","80","","","Percent of Total Billed Charges","neg_dollar:$445.60;Percent of Total Billed Charges","512.44","92","","","Percent of Total Billed Charges","neg_dollar:$512.44","289.64","52","","","Percent of Total Billed Charges","neg_dollar:$289.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","289.64","52","","","Percent of Total Billed Charges","neg_dollar:$289.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","289.00","557.00",""
"INJ ANESTH/STER GENICULAR NRV BRANCH","64454","CPT","60000281","CDM","761","RC","","Facility","Outpatient","","","794","635.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","412.88","52","","","Percent of Total Billed Charges","neg_dollar:$412.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","794.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","412.88","52","","","Percent of Total Billed Charges","neg_dollar:$412.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","412.88","52","","","Percent of Total Billed Charges","neg_dollar:$412.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","412.88","52","","","Percent of Total Billed Charges","neg_dollar:$412.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","682.84","86","","","Percent of Total Billed Charges","neg_dollar:$682.84","555.80","70","","","Percent of Total Billed Charges","neg_dollar:$555.80","412.88","52","","","Percent of Total Billed Charges","neg_dollar:$412.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","466.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$466.47;102% of Medicaid interim rate","595.50","75","","","Percent of Total Billed Charges","neg_dollar:$595.50","682.84","86","","","Percent of Total Billed Charges","neg_dollar:$682.84","555.80","70","","","Percent of Total Billed Charges","neg_dollar:$555.80","452.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$452.58;103.5% of Medicaid interim rate","794.00","150","","","Percent of Total Billed Charges","neg_dollar:$1227.56;150% of Medicaid interim rate","635.20","80","","","Percent of Total Billed Charges","neg_dollar:$635.20;Percent of Total Billed Charges","730.48","92","","","Percent of Total Billed Charges","neg_dollar:$730.48","412.88","52","","","Percent of Total Billed Charges","neg_dollar:$412.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","412.88","52","","","Percent of Total Billed Charges","neg_dollar:$412.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","412.00","794.00",""
"INJ(S) FORAMEN EPIDURAL C/T SGL LEV","64479","CPT","60000043","CDM","761","RC","","Facility","Outpatient","","","2301","1840.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1978.86","86","","","Percent of Total Billed Charges","neg_dollar:$1978.86","1610.69","70","","","Percent of Total Billed Charges","neg_dollar:$1610.69","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","1351.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$1351.83;102% of Medicaid interim rate","1725.75","75","","","Percent of Total Billed Charges","neg_dollar:$1725.75","1978.86","86","","","Percent of Total Billed Charges","neg_dollar:$1978.86","1610.69","70","","","Percent of Total Billed Charges","neg_dollar:$1610.69","1311.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$1311.57;103.5% of Medicaid interim rate","2301.00","150","","","Percent of Total Billed Charges","neg_dollar:$3557.46;150% of Medicaid interim rate","1840.80","80","","","Percent of Total Billed Charges","neg_dollar:$1840.80;Percent of Total Billed Charges","2116.92","92","","","Percent of Total Billed Charges","neg_dollar:$2116.92","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2301.00",""
"INJ(S) FORAMEN EPID C/T ADDTL LEV","64480","CPT","60000045","CDM","761","RC","","Facility","Outpatient","","","1106","884.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","951.16","86","","","Percent of Total Billed Charges","neg_dollar:$951.16","774.19","70","","","Percent of Total Billed Charges","neg_dollar:$774.19","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","649.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$649.77;102% of Medicaid interim rate","829.50","75","","","Percent of Total Billed Charges","neg_dollar:$829.50","951.16","86","","","Percent of Total Billed Charges","neg_dollar:$951.16","774.19","70","","","Percent of Total Billed Charges","neg_dollar:$774.19","630.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$630.42;103.5% of Medicaid interim rate","1106.00","150","","","Percent of Total Billed Charges","neg_dollar:$1709.93;150% of Medicaid interim rate","884.80","80","","","Percent of Total Billed Charges","neg_dollar:$884.80;Percent of Total Billed Charges","1017.52","92","","","Percent of Total Billed Charges","neg_dollar:$1017.52","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","575.00","1106.00",""
"INJ(S) FORAMEN EPIDURAL L/S SGL LEV","64483","CPT","60000047","CDM","360","RC","","Facility","Outpatient","","","2301","1840.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1978.86","86","","","Percent of Total Billed Charges","neg_dollar:$1978.86","1610.69","70","","","Percent of Total Billed Charges","neg_dollar:$1610.69","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","1351.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$1351.83;102% of Medicaid interim rate","1725.75","75","","","Percent of Total Billed Charges","neg_dollar:$1725.75","1978.86","86","","","Percent of Total Billed Charges","neg_dollar:$1978.86","1610.69","70","","","Percent of Total Billed Charges","neg_dollar:$1610.69","1311.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$1311.57;103.5% of Medicaid interim rate","2301.00","150","","","Percent of Total Billed Charges","neg_dollar:$3557.46;150% of Medicaid interim rate","1840.80","80","","","Percent of Total Billed Charges","neg_dollar:$1840.80;Percent of Total Billed Charges","2116.92","92","","","Percent of Total Billed Charges","neg_dollar:$2116.92","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2301.00",""
"INJ(S) FORAMEN EPID L/S SGL LEV BILAT","64483","CPT","60000048","CDM","761","RC","50","Facility","Outpatient","","","3449","2759.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2966.14","86","","","Percent of Total Billed Charges","neg_dollar:$2966.14","2414.29","70","","","Percent of Total Billed Charges","neg_dollar:$2414.29","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","2026.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$2026.28;102% of Medicaid interim rate","2586.75","75","","","Percent of Total Billed Charges","neg_dollar:$2586.75","2966.14","86","","","Percent of Total Billed Charges","neg_dollar:$2966.14","2414.29","70","","","Percent of Total Billed Charges","neg_dollar:$2414.29","1965.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$1965.92;103.5% of Medicaid interim rate","3449.00","150","","","Percent of Total Billed Charges","neg_dollar:$5332.32;150% of Medicaid interim rate","2759.20","80","","","Percent of Total Billed Charges","neg_dollar:$2759.20;Percent of Total Billed Charges","3173.08","92","","","Percent of Total Billed Charges","neg_dollar:$3173.08","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3449.00",""
"INJ(S) FORAMEN EPID L/S ADDTL LEV","64484","CPT","60000049","CDM","360","RC","","Facility","Outpatient","","","1106","884.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","951.16","86","","","Percent of Total Billed Charges","neg_dollar:$951.16","774.19","70","","","Percent of Total Billed Charges","neg_dollar:$774.19","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","649.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$649.77;102% of Medicaid interim rate","829.50","75","","","Percent of Total Billed Charges","neg_dollar:$829.50","951.16","86","","","Percent of Total Billed Charges","neg_dollar:$951.16","774.19","70","","","Percent of Total Billed Charges","neg_dollar:$774.19","630.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$630.42;103.5% of Medicaid interim rate","1106.00","150","","","Percent of Total Billed Charges","neg_dollar:$1709.93;150% of Medicaid interim rate","884.80","80","","","Percent of Total Billed Charges","neg_dollar:$884.80;Percent of Total Billed Charges","1017.52","92","","","Percent of Total Billed Charges","neg_dollar:$1017.52","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","575.12","52","","","Percent of Total Billed Charges","neg_dollar:$575.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","575.00","1106.00",""
"INJ(S) FORAMEN EPID L/S ADDTL LEV BILAT","64484","CPT","60000050","CDM","761","RC","50","Facility","Outpatient","","","1660","1328.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","863.20","52","","","Percent of Total Billed Charges","neg_dollar:$863.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","863.20","52","","","Percent of Total Billed Charges","neg_dollar:$863.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","863.20","52","","","Percent of Total Billed Charges","neg_dollar:$863.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","863.20","52","","","Percent of Total Billed Charges","neg_dollar:$863.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","1427.60","86","","","Percent of Total Billed Charges","neg_dollar:$1427.60","1162.00","70","","","Percent of Total Billed Charges","neg_dollar:$1162","863.20","52","","","Percent of Total Billed Charges","neg_dollar:$863.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","975.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$975.24;102% of Medicaid interim rate","1245.00","75","","","Percent of Total Billed Charges","neg_dollar:$1245","1427.60","86","","","Percent of Total Billed Charges","neg_dollar:$1427.60","1162.00","70","","","Percent of Total Billed Charges","neg_dollar:$1162","946.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$946.19;103.5% of Medicaid interim rate","1660.00","150","","","Percent of Total Billed Charges","neg_dollar:$2566.44;150% of Medicaid interim rate","1328.00","80","","","Percent of Total Billed Charges","neg_dollar:$1328;Percent of Total Billed Charges","1527.20","92","","","Percent of Total Billed Charges","neg_dollar:$1527.20","863.20","52","","","Percent of Total Billed Charges","neg_dollar:$863.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","863.20","52","","","Percent of Total Billed Charges","neg_dollar:$863.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1660.00",""
"TAP BLOCK BILAT BY INJ","64488","CPT","60000180","CDM","761","RC","","Facility","Outpatient","","","538","430.40","538.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","538.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","462.68","86","","","Percent of Total Billed Charges","neg_dollar:$462.68","376.59","70","","","Percent of Total Billed Charges","neg_dollar:$376.59","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","316.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$316.07;102% of Medicaid interim rate","403.50","75","","","Percent of Total Billed Charges","neg_dollar:$403.50","462.68","86","","","Percent of Total Billed Charges","neg_dollar:$462.68","376.59","70","","","Percent of Total Billed Charges","neg_dollar:$376.59","306.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$306.65;103.5% of Medicaid interim rate","538.00","150","","","Percent of Total Billed Charges","neg_dollar:$831.77;150% of Medicaid interim rate","430.40","80","","","Percent of Total Billed Charges","neg_dollar:$430.40;Percent of Total Billed Charges","494.96","92","","","Percent of Total Billed Charges","neg_dollar:$494.96","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.00","538.00",""
"INJ PARAVERT F JNT C/T 1 LEV","64490","CPT","60000051","CDM","761","RC","","Facility","Outpatient","","","2301","1840.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1978.86","86","","","Percent of Total Billed Charges","neg_dollar:$1978.86","1610.69","70","","","Percent of Total Billed Charges","neg_dollar:$1610.69","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","1351.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$1351.83;102% of Medicaid interim rate","1725.75","75","","","Percent of Total Billed Charges","neg_dollar:$1725.75","1978.86","86","","","Percent of Total Billed Charges","neg_dollar:$1978.86","1610.69","70","","","Percent of Total Billed Charges","neg_dollar:$1610.69","1311.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$1311.57;103.5% of Medicaid interim rate","2301.00","150","","","Percent of Total Billed Charges","neg_dollar:$3557.46;150% of Medicaid interim rate","1840.80","80","","","Percent of Total Billed Charges","neg_dollar:$1840.80;Percent of Total Billed Charges","2116.92","92","","","Percent of Total Billed Charges","neg_dollar:$2116.92","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2301.00",""
"INJ PARAVERT F JNT C/T 1 LEV BILAT","64490","CPT","60000052","CDM","360","RC","50","Facility","Outpatient","","","3449","2759.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2966.14","86","","","Percent of Total Billed Charges","neg_dollar:$2966.14","2414.29","70","","","Percent of Total Billed Charges","neg_dollar:$2414.29","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","2026.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$2026.28;102% of Medicaid interim rate","2586.75","75","","","Percent of Total Billed Charges","neg_dollar:$2586.75","2966.14","86","","","Percent of Total Billed Charges","neg_dollar:$2966.14","2414.29","70","","","Percent of Total Billed Charges","neg_dollar:$2414.29","1965.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$1965.92;103.5% of Medicaid interim rate","3449.00","150","","","Percent of Total Billed Charges","neg_dollar:$5332.32;150% of Medicaid interim rate","2759.20","80","","","Percent of Total Billed Charges","neg_dollar:$2759.20;Percent of Total Billed Charges","3173.08","92","","","Percent of Total Billed Charges","neg_dollar:$3173.08","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3449.00",""
"INJ PARAVERT F JNT C/T 2 LEV","64491","CPT","60000053","CDM","360","RC","","Facility","Outpatient","","","878","702.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","515.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$515.82;102% of Medicaid interim rate","658.50","75","","","Percent of Total Billed Charges","neg_dollar:$658.50","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","500.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$500.46;103.5% of Medicaid interim rate","878.00","150","","","Percent of Total Billed Charges","neg_dollar:$1357.43;150% of Medicaid interim rate","702.40","80","","","Percent of Total Billed Charges","neg_dollar:$702.40;Percent of Total Billed Charges","807.76","92","","","Percent of Total Billed Charges","neg_dollar:$807.76","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.00","878.00",""
"INJ PARAVERT F JNT C/T 2 LEV BILAT","64491","CPT","60000054","CDM","761","RC","50","Facility","Outpatient","","","1318","1054.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","774.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$774.32;102% of Medicaid interim rate","988.50","75","","","Percent of Total Billed Charges","neg_dollar:$988.50","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","751.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$751.26;103.5% of Medicaid interim rate","1318.00","150","","","Percent of Total Billed Charges","neg_dollar:$2037.69;150% of Medicaid interim rate","1054.40","80","","","Percent of Total Billed Charges","neg_dollar:$1054.40;Percent of Total Billed Charges","1212.56","92","","","Percent of Total Billed Charges","neg_dollar:$1212.56","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","685.00","1318.00",""
"INJ PARAVERT F JNT C/T 3 LEV","64492","CPT","60000055","CDM","360","RC","","Facility","Outpatient","","","878","702.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","515.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$515.82;102% of Medicaid interim rate","658.50","75","","","Percent of Total Billed Charges","neg_dollar:$658.50","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","500.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$500.46;103.5% of Medicaid interim rate","878.00","150","","","Percent of Total Billed Charges","neg_dollar:$1357.43;150% of Medicaid interim rate","702.40","80","","","Percent of Total Billed Charges","neg_dollar:$702.40;Percent of Total Billed Charges","807.76","92","","","Percent of Total Billed Charges","neg_dollar:$807.76","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.00","878.00",""
"INJ PARAVERT F JNT C/T 3 LEV BILAT","64492","CPT","60000056","CDM","360","RC","50","Facility","Outpatient","","","1318","1054.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","774.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$774.32;102% of Medicaid interim rate","988.50","75","","","Percent of Total Billed Charges","neg_dollar:$988.50","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","751.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$751.26;103.5% of Medicaid interim rate","1318.00","150","","","Percent of Total Billed Charges","neg_dollar:$2037.69;150% of Medicaid interim rate","1054.40","80","","","Percent of Total Billed Charges","neg_dollar:$1054.40;Percent of Total Billed Charges","1212.56","92","","","Percent of Total Billed Charges","neg_dollar:$1212.56","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","685.00","1318.00",""
"INJ PARAVERT F JNT L/S 1 LEV","64493","CPT","60000057","CDM","360","RC","","Facility","Outpatient","","","2301","1840.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","1978.86","86","","","Percent of Total Billed Charges","neg_dollar:$1978.86","1610.69","70","","","Percent of Total Billed Charges","neg_dollar:$1610.69","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","1351.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$1351.83;102% of Medicaid interim rate","1725.75","75","","","Percent of Total Billed Charges","neg_dollar:$1725.75","1978.86","86","","","Percent of Total Billed Charges","neg_dollar:$1978.86","1610.69","70","","","Percent of Total Billed Charges","neg_dollar:$1610.69","1311.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$1311.57;103.5% of Medicaid interim rate","2301.00","150","","","Percent of Total Billed Charges","neg_dollar:$3557.46;150% of Medicaid interim rate","1840.80","80","","","Percent of Total Billed Charges","neg_dollar:$1840.80;Percent of Total Billed Charges","2116.92","92","","","Percent of Total Billed Charges","neg_dollar:$2116.92","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1196.52","52","","","Percent of Total Billed Charges","neg_dollar:$1196.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2301.00",""
"INJ PARAVERT F JNT L/S 1 LEV BILAT","64493","CPT","60000058","CDM","360","RC","50","Facility","Outpatient","","","3449","2759.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2966.14","86","","","Percent of Total Billed Charges","neg_dollar:$2966.14","2414.29","70","","","Percent of Total Billed Charges","neg_dollar:$2414.29","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","2026.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$2026.28;102% of Medicaid interim rate","2586.75","75","","","Percent of Total Billed Charges","neg_dollar:$2586.75","2966.14","86","","","Percent of Total Billed Charges","neg_dollar:$2966.14","2414.29","70","","","Percent of Total Billed Charges","neg_dollar:$2414.29","1965.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$1965.92;103.5% of Medicaid interim rate","3449.00","150","","","Percent of Total Billed Charges","neg_dollar:$5332.32;150% of Medicaid interim rate","2759.20","80","","","Percent of Total Billed Charges","neg_dollar:$2759.20;Percent of Total Billed Charges","3173.08","92","","","Percent of Total Billed Charges","neg_dollar:$3173.08","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1793.48","52","","","Percent of Total Billed Charges","neg_dollar:$1793.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3449.00",""
"INJ PARAVERT F JNT L/S 2 LEV","64494","CPT","60000059","CDM","360","RC","","Facility","Outpatient","","","878","702.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","515.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$515.82;102% of Medicaid interim rate","658.50","75","","","Percent of Total Billed Charges","neg_dollar:$658.50","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","500.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$500.46;103.5% of Medicaid interim rate","878.00","150","","","Percent of Total Billed Charges","neg_dollar:$1357.43;150% of Medicaid interim rate","702.40","80","","","Percent of Total Billed Charges","neg_dollar:$702.40;Percent of Total Billed Charges","807.76","92","","","Percent of Total Billed Charges","neg_dollar:$807.76","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.00","878.00",""
"INJ PARAVERT F JNT L/S 2 LEV BILAT","64494","CPT","60000060","CDM","360","RC","50","Facility","Outpatient","","","1318","1054.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","774.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$774.32;102% of Medicaid interim rate","988.50","75","","","Percent of Total Billed Charges","neg_dollar:$988.50","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","751.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$751.26;103.5% of Medicaid interim rate","1318.00","150","","","Percent of Total Billed Charges","neg_dollar:$2037.69;150% of Medicaid interim rate","1054.40","80","","","Percent of Total Billed Charges","neg_dollar:$1054.40;Percent of Total Billed Charges","1212.56","92","","","Percent of Total Billed Charges","neg_dollar:$1212.56","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","685.00","1318.00",""
"INJ PARAVERT F JNT L/S 3 LEV","64495","CPT","60000061","CDM","360","RC","","Facility","Outpatient","","","878","702.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","515.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$515.82;102% of Medicaid interim rate","658.50","75","","","Percent of Total Billed Charges","neg_dollar:$658.50","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","500.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$500.46;103.5% of Medicaid interim rate","878.00","150","","","Percent of Total Billed Charges","neg_dollar:$1357.43;150% of Medicaid interim rate","702.40","80","","","Percent of Total Billed Charges","neg_dollar:$702.40;Percent of Total Billed Charges","807.76","92","","","Percent of Total Billed Charges","neg_dollar:$807.76","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.00","878.00",""
"INJ PARAVERT F JNT L/S 3 LEV BILAT","64495","CPT","60000062","CDM","761","RC","50","Facility","Outpatient","","","1318","1054.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","774.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$774.32;102% of Medicaid interim rate","988.50","75","","","Percent of Total Billed Charges","neg_dollar:$988.50","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","751.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$751.26;103.5% of Medicaid interim rate","1318.00","150","","","Percent of Total Billed Charges","neg_dollar:$2037.69;150% of Medicaid interim rate","1054.40","80","","","Percent of Total Billed Charges","neg_dollar:$1054.40;Percent of Total Billed Charges","1212.56","92","","","Percent of Total Billed Charges","neg_dollar:$1212.56","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","685.36","52","","","Percent of Total Billed Charges","neg_dollar:$685.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","685.00","1318.00",""
"INJ ANESTH STELLATE GANGLION","64510","CPT","60000022","CDM","761","RC","","Facility","Outpatient","","","2318","1854.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1993.48","86","","","Percent of Total Billed Charges","neg_dollar:$1993.48","1622.60","70","","","Percent of Total Billed Charges","neg_dollar:$1622.60","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","1361.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1361.82;102% of Medicaid interim rate","1738.50","75","","","Percent of Total Billed Charges","neg_dollar:$1738.50","1993.48","86","","","Percent of Total Billed Charges","neg_dollar:$1993.48","1622.60","70","","","Percent of Total Billed Charges","neg_dollar:$1622.60","1321.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$1321.26;103.5% of Medicaid interim rate","2318.00","150","","","Percent of Total Billed Charges","neg_dollar:$3583.74;150% of Medicaid interim rate","1854.40","80","","","Percent of Total Billed Charges","neg_dollar:$1854.40;Percent of Total Billed Charges","2132.56","92","","","Percent of Total Billed Charges","neg_dollar:$2132.56","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2318.00",""
"INJ ANESTH LUMB/THOR SYMPATHETIC","64520","CPT","60000023","CDM","761","RC","","Facility","Outpatient","","","2318","1854.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1993.48","86","","","Percent of Total Billed Charges","neg_dollar:$1993.48","1622.60","70","","","Percent of Total Billed Charges","neg_dollar:$1622.60","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","1361.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1361.82;102% of Medicaid interim rate","1738.50","75","","","Percent of Total Billed Charges","neg_dollar:$1738.50","1993.48","86","","","Percent of Total Billed Charges","neg_dollar:$1993.48","1622.60","70","","","Percent of Total Billed Charges","neg_dollar:$1622.60","1321.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$1321.26;103.5% of Medicaid interim rate","2318.00","150","","","Percent of Total Billed Charges","neg_dollar:$3583.74;150% of Medicaid interim rate","1854.40","80","","","Percent of Total Billed Charges","neg_dollar:$1854.40;Percent of Total Billed Charges","2132.56","92","","","Percent of Total Billed Charges","neg_dollar:$2132.56","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","1205.36","52","","","Percent of Total Billed Charges","neg_dollar:$1205.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2318.00",""
"DESTR W NEUROLYTIC; INTERCOSTAL NRV","64620","CPT","60000091","CDM","360","RC","","Facility","Outpatient","","","559","447.20","559.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","290.68","52","","","Percent of Total Billed Charges","neg_dollar:$290.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","559.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","290.68","52","","","Percent of Total Billed Charges","neg_dollar:$290.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","290.68","52","","","Percent of Total Billed Charges","neg_dollar:$290.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","290.68","52","","","Percent of Total Billed Charges","neg_dollar:$290.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","480.74","86","","","Percent of Total Billed Charges","neg_dollar:$480.74","391.29","70","","","Percent of Total Billed Charges","neg_dollar:$391.29","290.68","52","","","Percent of Total Billed Charges","neg_dollar:$290.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","328.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$328.41;102% of Medicaid interim rate","419.25","75","","","Percent of Total Billed Charges","neg_dollar:$419.25","480.74","86","","","Percent of Total Billed Charges","neg_dollar:$480.74","391.29","70","","","Percent of Total Billed Charges","neg_dollar:$391.29","318.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$318.63;103.5% of Medicaid interim rate","559.00","150","","","Percent of Total Billed Charges","neg_dollar:$864.24;150% of Medicaid interim rate","447.20","80","","","Percent of Total Billed Charges","neg_dollar:$447.20;Percent of Total Billed Charges","514.28","92","","","Percent of Total Billed Charges","neg_dollar:$514.28","290.68","52","","","Percent of Total Billed Charges","neg_dollar:$290.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","290.68","52","","","Percent of Total Billed Charges","neg_dollar:$290.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","290.00","559.00",""
"DESTR W NEUROLYTIC GENICULAR NRV","64624","CPT","60000282","CDM","761","RC","","Facility","Outpatient","","","977","781.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","508.04","52","","","Percent of Total Billed Charges","neg_dollar:$508.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","508.04","52","","","Percent of Total Billed Charges","neg_dollar:$508.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","508.04","52","","","Percent of Total Billed Charges","neg_dollar:$508.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","508.04","52","","","Percent of Total Billed Charges","neg_dollar:$508.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","840.22","86","","","Percent of Total Billed Charges","neg_dollar:$840.22","683.90","70","","","Percent of Total Billed Charges","neg_dollar:$683.90","508.04","52","","","Percent of Total Billed Charges","neg_dollar:$508.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","573.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$573.98;102% of Medicaid interim rate","732.75","75","","","Percent of Total Billed Charges","neg_dollar:$732.75","840.22","86","","","Percent of Total Billed Charges","neg_dollar:$840.22","683.90","70","","","Percent of Total Billed Charges","neg_dollar:$683.90","556.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$556.89;103.5% of Medicaid interim rate","977.00","150","","","Percent of Total Billed Charges","neg_dollar:$1510.49;150% of Medicaid interim rate","781.60","80","","","Percent of Total Billed Charges","neg_dollar:$781.60;Percent of Total Billed Charges","898.84","92","","","Percent of Total Billed Charges","neg_dollar:$898.84","508.04","52","","","Percent of Total Billed Charges","neg_dollar:$508.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","508.04","52","","","Percent of Total Billed Charges","neg_dollar:$508.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","508.00","977.00",""
"RF ABLTJ SI JOINT NRV NRVTG","64625","CPT","60000283","CDM","761","RC","","Facility","Outpatient","","","1198","958.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","622.96","52","","","Percent of Total Billed Charges","neg_dollar:$622.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","622.96","52","","","Percent of Total Billed Charges","neg_dollar:$622.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","622.96","52","","","Percent of Total Billed Charges","neg_dollar:$622.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","622.96","52","","","Percent of Total Billed Charges","neg_dollar:$622.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1030.28","86","","","Percent of Total Billed Charges","neg_dollar:$1030.28","838.59","70","","","Percent of Total Billed Charges","neg_dollar:$838.59","622.96","52","","","Percent of Total Billed Charges","neg_dollar:$622.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","703.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$703.82;102% of Medicaid interim rate","898.50","75","","","Percent of Total Billed Charges","neg_dollar:$898.50","1030.28","86","","","Percent of Total Billed Charges","neg_dollar:$1030.28","838.59","70","","","Percent of Total Billed Charges","neg_dollar:$838.59","682.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$682.85;103.5% of Medicaid interim rate","1198.00","150","","","Percent of Total Billed Charges","neg_dollar:$1852.16;150% of Medicaid interim rate","958.40","80","","","Percent of Total Billed Charges","neg_dollar:$958.40;Percent of Total Billed Charges","1102.16","92","","","Percent of Total Billed Charges","neg_dollar:$1102.16","622.96","52","","","Percent of Total Billed Charges","neg_dollar:$622.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","622.96","52","","","Percent of Total Billed Charges","neg_dollar:$622.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","622.00","1198.00",""
"N BLOCK INJ COMMON DIGIT","64632","CPT","60000291","CDM","761","RC","","Facility","Outpatient","","","236","188.80","236.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","122.72","52","","","Percent of Total Billed Charges","neg_dollar:$122.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","236.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","122.72","52","","","Percent of Total Billed Charges","neg_dollar:$122.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","122.72","52","","","Percent of Total Billed Charges","neg_dollar:$122.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","122.72","52","","","Percent of Total Billed Charges","neg_dollar:$122.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","202.96","86","","","Percent of Total Billed Charges","neg_dollar:$202.96","165.20","70","","","Percent of Total Billed Charges","neg_dollar:$165.20","122.72","52","","","Percent of Total Billed Charges","neg_dollar:$122.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","138.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$138.64;102% of Medicaid interim rate","177.00","75","","","Percent of Total Billed Charges","neg_dollar:$177","202.96","86","","","Percent of Total Billed Charges","neg_dollar:$202.96","165.20","70","","","Percent of Total Billed Charges","neg_dollar:$165.20","134.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$134.51;103.5% of Medicaid interim rate","236.00","150","","","Percent of Total Billed Charges","neg_dollar:$364.86;150% of Medicaid interim rate","188.80","80","","","Percent of Total Billed Charges","neg_dollar:$188.80;Percent of Total Billed Charges","217.12","92","","","Percent of Total Billed Charges","neg_dollar:$217.12","122.72","52","","","Percent of Total Billed Charges","neg_dollar:$122.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","122.72","52","","","Percent of Total Billed Charges","neg_dollar:$122.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","122.00","236.00",""
"DESTROY CERV/THOR FACET JNT UNIL","64633","CPT","60000110","CDM","761","RC","","Facility","Outpatient","","","1598","1278.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1374.28","86","","","Percent of Total Billed Charges","neg_dollar:$1374.28","1118.60","70","","","Percent of Total Billed Charges","neg_dollar:$1118.60","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","938.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$938.82;102% of Medicaid interim rate","1198.50","75","","","Percent of Total Billed Charges","neg_dollar:$1198.50","1374.28","86","","","Percent of Total Billed Charges","neg_dollar:$1374.28","1118.60","70","","","Percent of Total Billed Charges","neg_dollar:$1118.60","910.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$910.85;103.5% of Medicaid interim rate","1598.00","150","","","Percent of Total Billed Charges","neg_dollar:$2470.58;150% of Medicaid interim rate","1278.40","80","","","Percent of Total Billed Charges","neg_dollar:$1278.40;Percent of Total Billed Charges","1470.16","92","","","Percent of Total Billed Charges","neg_dollar:$1470.16","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1598.00",""
"DESTROY CERV/THOR FACET JNT BILAT","64633","CPT","60000111","CDM","761","RC","50","Facility","Outpatient","","","2397","1917.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1246.44","52","","","Percent of Total Billed Charges","neg_dollar:$1246.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1246.44","52","","","Percent of Total Billed Charges","neg_dollar:$1246.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","1246.44","52","","","Percent of Total Billed Charges","neg_dollar:$1246.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","1246.44","52","","","Percent of Total Billed Charges","neg_dollar:$1246.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","2061.42","86","","","Percent of Total Billed Charges","neg_dollar:$2061.42","1677.89","70","","","Percent of Total Billed Charges","neg_dollar:$1677.89","1246.44","52","","","Percent of Total Billed Charges","neg_dollar:$1246.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","1408.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1408.23;102% of Medicaid interim rate","1797.75","75","","","Percent of Total Billed Charges","neg_dollar:$1797.75","2061.42","86","","","Percent of Total Billed Charges","neg_dollar:$2061.42","1677.89","70","","","Percent of Total Billed Charges","neg_dollar:$1677.89","1366.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$1366.29;103.5% of Medicaid interim rate","2397.00","150","","","Percent of Total Billed Charges","neg_dollar:$3705.88;150% of Medicaid interim rate","1917.60","80","","","Percent of Total Billed Charges","neg_dollar:$1917.60;Percent of Total Billed Charges","2205.24","92","","","Percent of Total Billed Charges","neg_dollar:$2205.24","1246.44","52","","","Percent of Total Billed Charges","neg_dollar:$1246.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","1246.44","52","","","Percent of Total Billed Charges","neg_dollar:$1246.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2397.00",""
"DESTROY C/TH FACET JNT ADDL UNIL","64634","CPT","60000112","CDM","761","RC","","Facility","Outpatient","","","758","606.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","394.16","52","","","Percent of Total Billed Charges","neg_dollar:$394.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","758.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","394.16","52","","","Percent of Total Billed Charges","neg_dollar:$394.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","394.16","52","","","Percent of Total Billed Charges","neg_dollar:$394.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","394.16","52","","","Percent of Total Billed Charges","neg_dollar:$394.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","651.88","86","","","Percent of Total Billed Charges","neg_dollar:$651.88","530.60","70","","","Percent of Total Billed Charges","neg_dollar:$530.60","394.16","52","","","Percent of Total Billed Charges","neg_dollar:$394.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","445.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$445.32;102% of Medicaid interim rate","568.50","75","","","Percent of Total Billed Charges","neg_dollar:$568.50","651.88","86","","","Percent of Total Billed Charges","neg_dollar:$651.88","530.60","70","","","Percent of Total Billed Charges","neg_dollar:$530.60","432.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$432.05;103.5% of Medicaid interim rate","758.00","150","","","Percent of Total Billed Charges","neg_dollar:$1171.90;150% of Medicaid interim rate","606.40","80","","","Percent of Total Billed Charges","neg_dollar:$606.40;Percent of Total Billed Charges","697.36","92","","","Percent of Total Billed Charges","neg_dollar:$697.36","394.16","52","","","Percent of Total Billed Charges","neg_dollar:$394.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","394.16","52","","","Percent of Total Billed Charges","neg_dollar:$394.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","394.00","758.00",""
"DESTROY C/TH FACET JNT ADDL BILAT","64634","CPT","60000113","CDM","761","RC","50","Facility","Outpatient","","","1138","910.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","591.76","52","","","Percent of Total Billed Charges","neg_dollar:$591.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","591.76","52","","","Percent of Total Billed Charges","neg_dollar:$591.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","591.76","52","","","Percent of Total Billed Charges","neg_dollar:$591.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","591.76","52","","","Percent of Total Billed Charges","neg_dollar:$591.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","978.68","86","","","Percent of Total Billed Charges","neg_dollar:$978.68","796.59","70","","","Percent of Total Billed Charges","neg_dollar:$796.59","591.76","52","","","Percent of Total Billed Charges","neg_dollar:$591.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","668.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$668.57;102% of Medicaid interim rate","853.50","75","","","Percent of Total Billed Charges","neg_dollar:$853.50","978.68","86","","","Percent of Total Billed Charges","neg_dollar:$978.68","796.59","70","","","Percent of Total Billed Charges","neg_dollar:$796.59","648.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$648.66;103.5% of Medicaid interim rate","1138.00","150","","","Percent of Total Billed Charges","neg_dollar:$1759.40;150% of Medicaid interim rate","910.40","80","","","Percent of Total Billed Charges","neg_dollar:$910.40;Percent of Total Billed Charges","1046.96","92","","","Percent of Total Billed Charges","neg_dollar:$1046.96","591.76","52","","","Percent of Total Billed Charges","neg_dollar:$591.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","591.76","52","","","Percent of Total Billed Charges","neg_dollar:$591.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","591.00","1138.00",""
"DESTROY LUMB/SAC FACET JNT UNIL","64635","CPT","60000114","CDM","761","RC","","Facility","Outpatient","","","1683","1346.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","875.16","52","","","Percent of Total Billed Charges","neg_dollar:$875.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","875.16","52","","","Percent of Total Billed Charges","neg_dollar:$875.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","875.16","52","","","Percent of Total Billed Charges","neg_dollar:$875.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","875.16","52","","","Percent of Total Billed Charges","neg_dollar:$875.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1447.37","86","","","Percent of Total Billed Charges","neg_dollar:$1447.37","1178.10","70","","","Percent of Total Billed Charges","neg_dollar:$1178.10","875.16","52","","","Percent of Total Billed Charges","neg_dollar:$875.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","988.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$988.76;102% of Medicaid interim rate","1262.25","75","","","Percent of Total Billed Charges","neg_dollar:$1262.25","1447.37","86","","","Percent of Total Billed Charges","neg_dollar:$1447.37","1178.10","70","","","Percent of Total Billed Charges","neg_dollar:$1178.10","959.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$959.31;103.5% of Medicaid interim rate","1683.00","150","","","Percent of Total Billed Charges","neg_dollar:$2602;150% of Medicaid interim rate","1346.40","80","","","Percent of Total Billed Charges","neg_dollar:$1346.40;Percent of Total Billed Charges","1548.36","92","","","Percent of Total Billed Charges","neg_dollar:$1548.36","875.16","52","","","Percent of Total Billed Charges","neg_dollar:$875.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","875.16","52","","","Percent of Total Billed Charges","neg_dollar:$875.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1683.00",""
"DESTROY LUMB/SAC FACET JNT BILAT","64635","CPT","60000115","CDM","761","RC","50","Facility","Outpatient","","","2524","2019.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1312.48","52","","","Percent of Total Billed Charges","neg_dollar:$1312.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1312.48","52","","","Percent of Total Billed Charges","neg_dollar:$1312.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1312.48","52","","","Percent of Total Billed Charges","neg_dollar:$1312.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1312.48","52","","","Percent of Total Billed Charges","neg_dollar:$1312.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2170.64","86","","","Percent of Total Billed Charges","neg_dollar:$2170.64","1766.80","70","","","Percent of Total Billed Charges","neg_dollar:$1766.80","1312.48","52","","","Percent of Total Billed Charges","neg_dollar:$1312.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","1482.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$1482.84;102% of Medicaid interim rate","1893.00","75","","","Percent of Total Billed Charges","neg_dollar:$1893","2170.64","86","","","Percent of Total Billed Charges","neg_dollar:$2170.64","1766.80","70","","","Percent of Total Billed Charges","neg_dollar:$1766.80","1438.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$1438.67;103.5% of Medicaid interim rate","2524.00","150","","","Percent of Total Billed Charges","neg_dollar:$3902.23;150% of Medicaid interim rate","2019.20","80","","","Percent of Total Billed Charges","neg_dollar:$2019.20;Percent of Total Billed Charges","2322.08","92","","","Percent of Total Billed Charges","neg_dollar:$2322.08","1312.48","52","","","Percent of Total Billed Charges","neg_dollar:$1312.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1312.48","52","","","Percent of Total Billed Charges","neg_dollar:$1312.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2524.00",""
"DESTROY L/S FACET JNT ADDL UNIL","64636","CPT","60000116","CDM","761","RC","","Facility","Outpatient","","","733","586.40","733.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","733.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","630.38","86","","","Percent of Total Billed Charges","neg_dollar:$630.38","513.10","70","","","Percent of Total Billed Charges","neg_dollar:$513.10","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","430.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$430.63;102% of Medicaid interim rate","549.75","75","","","Percent of Total Billed Charges","neg_dollar:$549.75","630.38","86","","","Percent of Total Billed Charges","neg_dollar:$630.38","513.10","70","","","Percent of Total Billed Charges","neg_dollar:$513.10","417.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$417.80;103.5% of Medicaid interim rate","733.00","150","","","Percent of Total Billed Charges","neg_dollar:$1133.25;150% of Medicaid interim rate","586.40","80","","","Percent of Total Billed Charges","neg_dollar:$586.40;Percent of Total Billed Charges","674.36","92","","","Percent of Total Billed Charges","neg_dollar:$674.36","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","381.00","733.00",""
"DESTROY L/S FACET JNT ADDL BILAT","64636","CPT","60000117","CDM","761","RC","50","Facility","Outpatient","","","1098","878.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","944.28","86","","","Percent of Total Billed Charges","neg_dollar:$944.28","768.59","70","","","Percent of Total Billed Charges","neg_dollar:$768.59","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","645.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$645.07;102% of Medicaid interim rate","823.50","75","","","Percent of Total Billed Charges","neg_dollar:$823.50","944.28","86","","","Percent of Total Billed Charges","neg_dollar:$944.28","768.59","70","","","Percent of Total Billed Charges","neg_dollar:$768.59","625.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$625.85;103.5% of Medicaid interim rate","1098.00","150","","","Percent of Total Billed Charges","neg_dollar:$1697.56;150% of Medicaid interim rate","878.40","80","","","Percent of Total Billed Charges","neg_dollar:$878.40;Percent of Total Billed Charges","1010.16","92","","","Percent of Total Billed Charges","neg_dollar:$1010.16","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","570.96","52","","","Percent of Total Billed Charges","neg_dollar:$570.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","570.00","1098.00",""
"DESTR W NEUROLYTIC OTHER PERIPH NRV","64640","CPT","60000026","CDM","761","RC","","Facility","Outpatient","","","763","610.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","396.76","52","","","Percent of Total Billed Charges","neg_dollar:$396.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","763.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","396.76","52","","","Percent of Total Billed Charges","neg_dollar:$396.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","396.76","52","","","Percent of Total Billed Charges","neg_dollar:$396.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","396.76","52","","","Percent of Total Billed Charges","neg_dollar:$396.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","656.18","86","","","Percent of Total Billed Charges","neg_dollar:$656.18","534.10","70","","","Percent of Total Billed Charges","neg_dollar:$534.10","396.76","52","","","Percent of Total Billed Charges","neg_dollar:$396.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","448.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$448.26;102% of Medicaid interim rate","572.25","75","","","Percent of Total Billed Charges","neg_dollar:$572.25","656.18","86","","","Percent of Total Billed Charges","neg_dollar:$656.18","534.10","70","","","Percent of Total Billed Charges","neg_dollar:$534.10","434.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$434.90;103.5% of Medicaid interim rate","763.00","150","","","Percent of Total Billed Charges","neg_dollar:$1179.63;150% of Medicaid interim rate","610.40","80","","","Percent of Total Billed Charges","neg_dollar:$610.40;Percent of Total Billed Charges","701.96","92","","","Percent of Total Billed Charges","neg_dollar:$701.96","396.76","52","","","Percent of Total Billed Charges","neg_dollar:$396.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","396.76","52","","","Percent of Total Billed Charges","neg_dollar:$396.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","396.00","763.00",""
"DSTR W NEUROLYTIC OTHER PERIPH NRV BILAT","64640","CPT","60000124","CDM","761","RC","50","Facility","Outpatient","","","1146","916.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","595.92","52","","","Percent of Total Billed Charges","neg_dollar:$595.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","595.92","52","","","Percent of Total Billed Charges","neg_dollar:$595.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","595.92","52","","","Percent of Total Billed Charges","neg_dollar:$595.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","595.92","52","","","Percent of Total Billed Charges","neg_dollar:$595.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","985.56","86","","","Percent of Total Billed Charges","neg_dollar:$985.56","802.19","70","","","Percent of Total Billed Charges","neg_dollar:$802.19","595.92","52","","","Percent of Total Billed Charges","neg_dollar:$595.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","673.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$673.27;102% of Medicaid interim rate","859.50","75","","","Percent of Total Billed Charges","neg_dollar:$859.50","985.56","86","","","Percent of Total Billed Charges","neg_dollar:$985.56","802.19","70","","","Percent of Total Billed Charges","neg_dollar:$802.19","653.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$653.21;103.5% of Medicaid interim rate","1146.00","150","","","Percent of Total Billed Charges","neg_dollar:$1771.77;150% of Medicaid interim rate","916.80","80","","","Percent of Total Billed Charges","neg_dollar:$916.80;Percent of Total Billed Charges","1054.32","92","","","Percent of Total Billed Charges","neg_dollar:$1054.32","595.92","52","","","Percent of Total Billed Charges","neg_dollar:$595.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","595.92","52","","","Percent of Total Billed Charges","neg_dollar:$595.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","595.00","1146.00",""
"UNLISTED PROCEDURE NERVOUS SYSTEM","64999","CPT","60000164","CDM","360","RC","","Facility","Outpatient","","","860","688.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","505.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$505.24;102% of Medicaid interim rate","645.00","75","","","Percent of Total Billed Charges","neg_dollar:$645","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","490.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$490.19;103.5% of Medicaid interim rate","860.00","150","","","Percent of Total Billed Charges","neg_dollar:$1329.60;150% of Medicaid interim rate","688.00","80","","","Percent of Total Billed Charges","neg_dollar:$688;Percent of Total Billed Charges","791.20","92","","","Percent of Total Billed Charges","neg_dollar:$791.20","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","447.00","860.00",""
"REM FB CONJUNCTIVA SUPERFICIAL","65205","CPT","60000027","CDM","450","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"REM FB EXT EYE CORNEAL WO SLIT LAMP","65220","CPT","60000029","CDM","450","RC","","Facility","Outpatient","","","404","323.20","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","404.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.34;102% of Medicaid interim rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","230.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.27;103.5% of Medicaid interim rate","404.00","150","","","Percent of Total Billed Charges","neg_dollar:$624.60;150% of Medicaid interim rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.08","52","","","Percent of Total Billed Charges","neg_dollar:$210.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","404.00",""
"REM FB CORNEAL W SLIT LAMP","65222","CPT","60000030","CDM","450","RC","","Facility","Outpatient","","","312","249.60","312.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","312.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","268.32","86","","","Percent of Total Billed Charges","neg_dollar:$268.32","218.39","70","","","Percent of Total Billed Charges","neg_dollar:$218.39","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","183.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$183.29;102% of Medicaid interim rate","234.00","75","","","Percent of Total Billed Charges","neg_dollar:$234","268.32","86","","","Percent of Total Billed Charges","neg_dollar:$268.32","218.39","70","","","Percent of Total Billed Charges","neg_dollar:$218.39","177.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$177.83;103.5% of Medicaid interim rate","312.00","150","","","Percent of Total Billed Charges","neg_dollar:$482.36;150% of Medicaid interim rate","249.60","80","","","Percent of Total Billed Charges","neg_dollar:$249.60;Percent of Total Billed Charges","287.04","92","","","Percent of Total Billed Charges","neg_dollar:$287.04","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.00","312.00",""
"REM FB EXT AUDITORY CANAL WO ANESTH","69200","CPT","60000033","CDM","450","RC","","Facility","Outpatient","","","128","102.40","128.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","128.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.08","86","","","Percent of Total Billed Charges","neg_dollar:$110.08","89.60","70","","","Percent of Total Billed Charges","neg_dollar:$89.60","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","75.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$75.19;102% of Medicaid interim rate","96.00","75","","","Percent of Total Billed Charges","neg_dollar:$96","110.08","86","","","Percent of Total Billed Charges","neg_dollar:$110.08","89.60","70","","","Percent of Total Billed Charges","neg_dollar:$89.60","72.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$72.96;103.5% of Medicaid interim rate","128.00","150","","","Percent of Total Billed Charges","neg_dollar:$197.89;150% of Medicaid interim rate","102.40","80","","","Percent of Total Billed Charges","neg_dollar:$102.40;Percent of Total Billed Charges","117.76","92","","","Percent of Total Billed Charges","neg_dollar:$117.76","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","66.00","128.00",""
"REMOVE IMPACTED EAR WAX UNI","69209","CPT","60000201","CDM","360","RC","","Facility","Outpatient","","","41","32.80","41.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","21.32","52","","","Percent of Total Billed Charges","neg_dollar:$21.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","41.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","21.32","52","","","Percent of Total Billed Charges","neg_dollar:$21.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.32","52","","","Percent of Total Billed Charges","neg_dollar:$21.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.32","52","","","Percent of Total Billed Charges","neg_dollar:$21.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","35.26","86","","","Percent of Total Billed Charges","neg_dollar:$35.26","28.70","70","","","Percent of Total Billed Charges","neg_dollar:$28.70","21.32","52","","","Percent of Total Billed Charges","neg_dollar:$21.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","24.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.08;102% of Medicaid interim rate","30.75","75","","","Percent of Total Billed Charges","neg_dollar:$30.75","35.26","86","","","Percent of Total Billed Charges","neg_dollar:$35.26","28.70","70","","","Percent of Total Billed Charges","neg_dollar:$28.70","23.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$23.36;103.5% of Medicaid interim rate","41.00","150","","","Percent of Total Billed Charges","neg_dollar:$63.38;150% of Medicaid interim rate","32.80","80","","","Percent of Total Billed Charges","neg_dollar:$32.80;Percent of Total Billed Charges","37.72","92","","","Percent of Total Billed Charges","neg_dollar:$37.72","21.32","52","","","Percent of Total Billed Charges","neg_dollar:$21.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","21.32","52","","","Percent of Total Billed Charges","neg_dollar:$21.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","21.00","41.00",""
"REMOVAL IMPACTED CERUMEN (EARWAX)","69210","CPT","60000034","CDM","360","RC","","Facility","Outpatient","","","248","198.40","248.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","248.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","213.28","86","","","Percent of Total Billed Charges","neg_dollar:$213.28","173.60","70","","","Percent of Total Billed Charges","neg_dollar:$173.60","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","145.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$145.69;102% of Medicaid interim rate","186.00","75","","","Percent of Total Billed Charges","neg_dollar:$186","213.28","86","","","Percent of Total Billed Charges","neg_dollar:$213.28","173.60","70","","","Percent of Total Billed Charges","neg_dollar:$173.60","141.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$141.35;103.5% of Medicaid interim rate","248.00","150","","","Percent of Total Billed Charges","neg_dollar:$383.42;150% of Medicaid interim rate","198.40","80","","","Percent of Total Billed Charges","neg_dollar:$198.40;Percent of Total Billed Charges","228.16","92","","","Percent of Total Billed Charges","neg_dollar:$228.16","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","128.00","248.00",""
"FOREIGN BODY IN EYE","70030","CPT","70000310","CDM","320","RC","","Facility","Outpatient","","","290","232.00","290.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","150.80","52","","","Percent of Total Billed Charges","neg_dollar:$150.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","290.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","150.80","52","","","Percent of Total Billed Charges","neg_dollar:$150.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","150.80","52","","","Percent of Total Billed Charges","neg_dollar:$150.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","150.80","52","","","Percent of Total Billed Charges","neg_dollar:$150.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","249.40","86","","","Percent of Total Billed Charges","neg_dollar:$249.40","203.00","70","","","Percent of Total Billed Charges","neg_dollar:$203","150.80","52","","","Percent of Total Billed Charges","neg_dollar:$150.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","170.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$170.37;102% of Medicaid interim rate","217.50","75","","","Percent of Total Billed Charges","neg_dollar:$217.50","249.40","86","","","Percent of Total Billed Charges","neg_dollar:$249.40","203.00","70","","","Percent of Total Billed Charges","neg_dollar:$203","165.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$165.29;103.5% of Medicaid interim rate","290.00","150","","","Percent of Total Billed Charges","neg_dollar:$448.35;150% of Medicaid interim rate","232.00","80","","","Percent of Total Billed Charges","neg_dollar:$232;Percent of Total Billed Charges","","","","229.00","Fee Schedule","","150.80","52","","","Percent of Total Billed Charges","neg_dollar:$150.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","150.80","52","","","Percent of Total Billed Charges","neg_dollar:$150.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","150.00","290.00",""
"MANDIBLE MIN 4 VIEWS","70110","CPT","70000002","CDM","320","RC","","Facility","Outpatient","","","340","272.00","340.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","340.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","292.40","86","","","Percent of Total Billed Charges","neg_dollar:$292.40","237.99","70","","","Percent of Total Billed Charges","neg_dollar:$237.99","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","199.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$199.74;102% of Medicaid interim rate","255.00","75","","","Percent of Total Billed Charges","neg_dollar:$255","292.40","86","","","Percent of Total Billed Charges","neg_dollar:$292.40","237.99","70","","","Percent of Total Billed Charges","neg_dollar:$237.99","193.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$193.79;103.5% of Medicaid interim rate","340.00","150","","","Percent of Total Billed Charges","neg_dollar:$525.65;150% of Medicaid interim rate","272.00","80","","","Percent of Total Billed Charges","neg_dollar:$272;Percent of Total Billed Charges","","","","340.00","Fee Schedule","","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","176.00","340.00",""
"MASTOIDS MIN 3 VIEWS EACH SIDE","70130","CPT","70000003","CDM","320","RC","","Facility","Outpatient","","","623","498.40","623.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","323.96","52","","","Percent of Total Billed Charges","neg_dollar:$323.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","623.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","323.96","52","","","Percent of Total Billed Charges","neg_dollar:$323.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","323.96","52","","","Percent of Total Billed Charges","neg_dollar:$323.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","323.96","52","","","Percent of Total Billed Charges","neg_dollar:$323.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","535.78","86","","","Percent of Total Billed Charges","neg_dollar:$535.78","436.09","70","","","Percent of Total Billed Charges","neg_dollar:$436.09","323.96","52","","","Percent of Total Billed Charges","neg_dollar:$323.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","366.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$366.01;102% of Medicaid interim rate","467.25","75","","","Percent of Total Billed Charges","neg_dollar:$467.25","535.78","86","","","Percent of Total Billed Charges","neg_dollar:$535.78","436.09","70","","","Percent of Total Billed Charges","neg_dollar:$436.09","355.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$355.10;103.5% of Medicaid interim rate","623.00","150","","","Percent of Total Billed Charges","neg_dollar:$963.18;150% of Medicaid interim rate","498.40","80","","","Percent of Total Billed Charges","neg_dollar:$498.40;Percent of Total Billed Charges","","","","623.00","Fee Schedule","","323.96","52","","","Percent of Total Billed Charges","neg_dollar:$323.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","323.96","52","","","Percent of Total Billed Charges","neg_dollar:$323.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","323.00","623.00",""
"FACIAL BONES LESS THAN 3 VIEWS","70140","CPT","70000005","CDM","320","RC","","Facility","Outpatient","","","234","187.20","234.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","234.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","86","","","Percent of Total Billed Charges","neg_dollar:$201.24","163.79","70","","","Percent of Total Billed Charges","neg_dollar:$163.79","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","137.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$137.47;102% of Medicaid interim rate","175.50","75","","","Percent of Total Billed Charges","neg_dollar:$175.50","201.24","86","","","Percent of Total Billed Charges","neg_dollar:$201.24","163.79","70","","","Percent of Total Billed Charges","neg_dollar:$163.79","133.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$133.38;103.5% of Medicaid interim rate","234.00","150","","","Percent of Total Billed Charges","neg_dollar:$361.77;150% of Medicaid interim rate","187.20","80","","","Percent of Total Billed Charges","neg_dollar:$187.20;Percent of Total Billed Charges","","","","234.00","Fee Schedule","","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","234.00",""
"FACIAL BONES MIN 3 VIEWS","70150","CPT","70000006","CDM","320","RC","","Facility","Outpatient","","","494","395.20","494.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","494.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","424.84","86","","","Percent of Total Billed Charges","neg_dollar:$424.84","345.79","70","","","Percent of Total Billed Charges","neg_dollar:$345.79","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","290.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$290.22;102% of Medicaid interim rate","370.50","75","","","Percent of Total Billed Charges","neg_dollar:$370.50","424.84","86","","","Percent of Total Billed Charges","neg_dollar:$424.84","345.79","70","","","Percent of Total Billed Charges","neg_dollar:$345.79","281.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$281.58;103.5% of Medicaid interim rate","494.00","150","","","Percent of Total Billed Charges","neg_dollar:$763.74;150% of Medicaid interim rate","395.20","80","","","Percent of Total Billed Charges","neg_dollar:$395.20;Percent of Total Billed Charges","","","","391.00","Fee Schedule","","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","256.00","494.00",""
"NASAL BONES MIN 3 VIEWS","70160","CPT","70000007","CDM","320","RC","","Facility","Outpatient","","","308","246.40","308.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","160.16","52","","","Percent of Total Billed Charges","neg_dollar:$160.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","308.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","160.16","52","","","Percent of Total Billed Charges","neg_dollar:$160.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","160.16","52","","","Percent of Total Billed Charges","neg_dollar:$160.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","160.16","52","","","Percent of Total Billed Charges","neg_dollar:$160.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","264.88","86","","","Percent of Total Billed Charges","neg_dollar:$264.88","215.60","70","","","Percent of Total Billed Charges","neg_dollar:$215.60","160.16","52","","","Percent of Total Billed Charges","neg_dollar:$160.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","180.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$180.94;102% of Medicaid interim rate","231.00","75","","","Percent of Total Billed Charges","neg_dollar:$231","264.88","86","","","Percent of Total Billed Charges","neg_dollar:$264.88","215.60","70","","","Percent of Total Billed Charges","neg_dollar:$215.60","175.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$175.55;103.5% of Medicaid interim rate","308.00","150","","","Percent of Total Billed Charges","neg_dollar:$476.18;150% of Medicaid interim rate","246.40","80","","","Percent of Total Billed Charges","neg_dollar:$246.40;Percent of Total Billed Charges","","","","216.00","Fee Schedule","","160.16","52","","","Percent of Total Billed Charges","neg_dollar:$160.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","160.16","52","","","Percent of Total Billed Charges","neg_dollar:$160.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","160.00","308.00",""
"ORBITS COMPL MIN 4 VIEWS","70200","CPT","70000008","CDM","320","RC","","Facility","Outpatient","","","437","349.60","437.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","437.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","375.82","86","","","Percent of Total Billed Charges","neg_dollar:$375.82","305.90","70","","","Percent of Total Billed Charges","neg_dollar:$305.90","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","256.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$256.73;102% of Medicaid interim rate","327.75","75","","","Percent of Total Billed Charges","neg_dollar:$327.75","375.82","86","","","Percent of Total Billed Charges","neg_dollar:$375.82","305.90","70","","","Percent of Total Billed Charges","neg_dollar:$305.90","249.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.08;103.5% of Medicaid interim rate","437.00","150","","","Percent of Total Billed Charges","neg_dollar:$675.62;150% of Medicaid interim rate","349.60","80","","","Percent of Total Billed Charges","neg_dollar:$349.60;Percent of Total Billed Charges","","","","437.00","Fee Schedule","","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","227.24","52","","","Percent of Total Billed Charges","neg_dollar:$227.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","227.00","437.00",""
"SINUSES LESS THAN 3 VIEWS","70210","CPT","70000009","CDM","320","RC","","Facility","Outpatient","","","226","180.80","226.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","226.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","194.35","86","","","Percent of Total Billed Charges","neg_dollar:$194.35","158.20","70","","","Percent of Total Billed Charges","neg_dollar:$158.20","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","132.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$132.77;102% of Medicaid interim rate","169.50","75","","","Percent of Total Billed Charges","neg_dollar:$169.50","194.35","86","","","Percent of Total Billed Charges","neg_dollar:$194.35","158.20","70","","","Percent of Total Billed Charges","neg_dollar:$158.20","128.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$128.82;103.5% of Medicaid interim rate","226.00","150","","","Percent of Total Billed Charges","neg_dollar:$349.40;150% of Medicaid interim rate","180.80","80","","","Percent of Total Billed Charges","neg_dollar:$180.80;Percent of Total Billed Charges","","","","226.00","Fee Schedule","","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","117.00","226.00",""
"SINUSES MIN 3 VIEWS","70220","CPT","70000010","CDM","320","RC","","Facility","Outpatient","","","387","309.60","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","227.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$227.36;102% of Medicaid interim rate","290.25","75","","","Percent of Total Billed Charges","neg_dollar:$290.25","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","220.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$220.58;103.5% of Medicaid interim rate","387.00","150","","","Percent of Total Billed Charges","neg_dollar:$598.32;150% of Medicaid interim rate","309.60","80","","","Percent of Total Billed Charges","neg_dollar:$309.60;Percent of Total Billed Charges","","","","387.00","Fee Schedule","","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.00","387.00",""
"SELLA TURCICA","70240","CPT","70000313","CDM","320","RC","","Facility","Outpatient","","","234","187.20","234.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","234.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","86","","","Percent of Total Billed Charges","neg_dollar:$201.24","163.79","70","","","Percent of Total Billed Charges","neg_dollar:$163.79","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","137.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$137.47;102% of Medicaid interim rate","175.50","75","","","Percent of Total Billed Charges","neg_dollar:$175.50","201.24","86","","","Percent of Total Billed Charges","neg_dollar:$201.24","163.79","70","","","Percent of Total Billed Charges","neg_dollar:$163.79","133.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$133.38;103.5% of Medicaid interim rate","234.00","150","","","Percent of Total Billed Charges","neg_dollar:$361.77;150% of Medicaid interim rate","187.20","80","","","Percent of Total Billed Charges","neg_dollar:$187.20;Percent of Total Billed Charges","","","","234.00","Fee Schedule","","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","121.68","52","","","Percent of Total Billed Charges","neg_dollar:$121.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","234.00",""
"SKULL LESS THAN 4 VIEWS","70250","CPT","70000011","CDM","320","RC","","Facility","Outpatient","","","387","309.60","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","227.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$227.36;102% of Medicaid interim rate","290.25","75","","","Percent of Total Billed Charges","neg_dollar:$290.25","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","220.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$220.58;103.5% of Medicaid interim rate","387.00","150","","","Percent of Total Billed Charges","neg_dollar:$598.32;150% of Medicaid interim rate","309.60","80","","","Percent of Total Billed Charges","neg_dollar:$309.60;Percent of Total Billed Charges","","","","387.00","Fee Schedule","","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.00","387.00",""
"SKULL MIN 4 VIEWS","70260","CPT","70000012","CDM","320","RC","","Facility","Outpatient","","","461","368.80","461.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","239.72","52","","","Percent of Total Billed Charges","neg_dollar:$239.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","461.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","239.72","52","","","Percent of Total Billed Charges","neg_dollar:$239.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","239.72","52","","","Percent of Total Billed Charges","neg_dollar:$239.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","239.72","52","","","Percent of Total Billed Charges","neg_dollar:$239.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","396.46","86","","","Percent of Total Billed Charges","neg_dollar:$396.46","322.70","70","","","Percent of Total Billed Charges","neg_dollar:$322.70","239.72","52","","","Percent of Total Billed Charges","neg_dollar:$239.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","270.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$270.83;102% of Medicaid interim rate","345.75","75","","","Percent of Total Billed Charges","neg_dollar:$345.75","396.46","86","","","Percent of Total Billed Charges","neg_dollar:$396.46","322.70","70","","","Percent of Total Billed Charges","neg_dollar:$322.70","262.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$262.77;103.5% of Medicaid interim rate","461.00","150","","","Percent of Total Billed Charges","neg_dollar:$712.72;150% of Medicaid interim rate","368.80","80","","","Percent of Total Billed Charges","neg_dollar:$368.80;Percent of Total Billed Charges","","","","461.00","Fee Schedule","","239.72","52","","","Percent of Total Billed Charges","neg_dollar:$239.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","239.72","52","","","Percent of Total Billed Charges","neg_dollar:$239.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","239.00","461.00",""
"TEETH PARTIAL EXAM < FULL MOUTH","70310","CPT","70000684","CDM","320","RC","","Facility","Outpatient","","","169","135.20","169.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","87.88","52","","","Percent of Total Billed Charges","neg_dollar:$87.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","169.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","87.88","52","","","Percent of Total Billed Charges","neg_dollar:$87.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","87.88","52","","","Percent of Total Billed Charges","neg_dollar:$87.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","87.88","52","","","Percent of Total Billed Charges","neg_dollar:$87.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","145.34","86","","","Percent of Total Billed Charges","neg_dollar:$145.34","118.30","70","","","Percent of Total Billed Charges","neg_dollar:$118.30","87.88","52","","","Percent of Total Billed Charges","neg_dollar:$87.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","99.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$99.28;102% of Medicaid interim rate","126.75","75","","","Percent of Total Billed Charges","neg_dollar:$126.75","145.34","86","","","Percent of Total Billed Charges","neg_dollar:$145.34","118.30","70","","","Percent of Total Billed Charges","neg_dollar:$118.30","96.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$96.33;103.5% of Medicaid interim rate","169.00","150","","","Percent of Total Billed Charges","neg_dollar:$261.28;150% of Medicaid interim rate","135.20","80","","","Percent of Total Billed Charges","neg_dollar:$135.20;Percent of Total Billed Charges","","","","169.00","Fee Schedule","","87.88","52","","","Percent of Total Billed Charges","neg_dollar:$87.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","87.88","52","","","Percent of Total Billed Charges","neg_dollar:$87.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","87.00","169.00",""
"TEETH COMPLETE FULL MOUTH","70320","CPT","70000314","CDM","320","RC","","Facility","Outpatient","","","240","192.00","240.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","240.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","206.40","86","","","Percent of Total Billed Charges","neg_dollar:$206.40","168.00","70","","","Percent of Total Billed Charges","neg_dollar:$168","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","140.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$140.99;102% of Medicaid interim rate","180.00","75","","","Percent of Total Billed Charges","neg_dollar:$180","206.40","86","","","Percent of Total Billed Charges","neg_dollar:$206.40","168.00","70","","","Percent of Total Billed Charges","neg_dollar:$168","136.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$136.79;103.5% of Medicaid interim rate","240.00","150","","","Percent of Total Billed Charges","neg_dollar:$371.05;150% of Medicaid interim rate","192.00","80","","","Percent of Total Billed Charges","neg_dollar:$192;Percent of Total Billed Charges","","","","240.00","Fee Schedule","","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","124.00","240.00",""
"TMJ UNILATERAL","70328","CPT","70000315","CDM","320","RC","","Facility","Outpatient","","","216","172.80","216.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","112.32","52","","","Percent of Total Billed Charges","neg_dollar:$112.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","216.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","112.32","52","","","Percent of Total Billed Charges","neg_dollar:$112.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","112.32","52","","","Percent of Total Billed Charges","neg_dollar:$112.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","112.32","52","","","Percent of Total Billed Charges","neg_dollar:$112.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","185.76","86","","","Percent of Total Billed Charges","neg_dollar:$185.76","151.20","70","","","Percent of Total Billed Charges","neg_dollar:$151.20","112.32","52","","","Percent of Total Billed Charges","neg_dollar:$112.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","126.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$126.89;102% of Medicaid interim rate","162.00","75","","","Percent of Total Billed Charges","neg_dollar:$162","185.76","86","","","Percent of Total Billed Charges","neg_dollar:$185.76","151.20","70","","","Percent of Total Billed Charges","neg_dollar:$151.20","123.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$123.11;103.5% of Medicaid interim rate","216.00","150","","","Percent of Total Billed Charges","neg_dollar:$333.94;150% of Medicaid interim rate","172.80","80","","","Percent of Total Billed Charges","neg_dollar:$172.80;Percent of Total Billed Charges","","","","216.00","Fee Schedule","","112.32","52","","","Percent of Total Billed Charges","neg_dollar:$112.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","112.32","52","","","Percent of Total Billed Charges","neg_dollar:$112.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","112.00","216.00",""
"TMJ BILATERAL","70330","CPT","70000013","CDM","320","RC","","Facility","Outpatient","","","425","340.00","425.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","221.00","52","","","Percent of Total Billed Charges","neg_dollar:$221;101% Medicare Outpatient Cost to Charge Ratio of 52%","425.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","221.00","52","","","Percent of Total Billed Charges","neg_dollar:$221;102% Medicare Outpatient Cost to Charge Ratio of 52%","221.00","52","","","Percent of Total Billed Charges","neg_dollar:$221;102% Medicare Outpatient Cost to Charge Ratio of 52%","221.00","52","","","Percent of Total Billed Charges","neg_dollar:$221;102% Medicare Outpatient Cost to Charge Ratio of 52%","365.50","86","","","Percent of Total Billed Charges","neg_dollar:$365.50","297.50","70","","","Percent of Total Billed Charges","neg_dollar:$297.50","221.00","52","","","Percent of Total Billed Charges","neg_dollar:$221;105% Medicare Outpatient Cost to Charge Ratio of 52%","249.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.68;102% of Medicaid interim rate","318.75","75","","","Percent of Total Billed Charges","neg_dollar:$318.75","365.50","86","","","Percent of Total Billed Charges","neg_dollar:$365.50","297.50","70","","","Percent of Total Billed Charges","neg_dollar:$297.50","242.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$242.24;103.5% of Medicaid interim rate","425.00","150","","","Percent of Total Billed Charges","neg_dollar:$657.07;150% of Medicaid interim rate","340.00","80","","","Percent of Total Billed Charges","neg_dollar:$340;Percent of Total Billed Charges","","","","425.00","Fee Schedule","","221.00","52","","","Percent of Total Billed Charges","neg_dollar:$221;100% Medicare Outpatient Cost to Charge Ratio of 52%","221.00","52","","","Percent of Total Billed Charges","neg_dollar:$221;100% Medicare Outpatient Cost to Charge Ratio of 52%","221.00","425.00",""
"MRI OF TMJ","70336","CPT","70000316","CDM","610","RC","","Facility","Outpatient","","","2886","2308.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1500.72","52","","","Percent of Total Billed Charges","neg_dollar:$1500.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1500.72","52","","","Percent of Total Billed Charges","neg_dollar:$1500.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1500.72","52","","","Percent of Total Billed Charges","neg_dollar:$1500.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1500.72","52","","","Percent of Total Billed Charges","neg_dollar:$1500.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","2481.96","86","","","Percent of Total Billed Charges","neg_dollar:$2481.96","2020.19","70","","","Percent of Total Billed Charges","neg_dollar:$2020.19","1500.72","52","","","Percent of Total Billed Charges","neg_dollar:$1500.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","1695.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$1695.52;102% of Medicaid interim rate","2164.50","75","","","Percent of Total Billed Charges","neg_dollar:$2164.50","2481.96","86","","","Percent of Total Billed Charges","neg_dollar:$2481.96","2020.19","70","","","Percent of Total Billed Charges","neg_dollar:$2020.19","1645.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$1645.01;103.5% of Medicaid interim rate","2886.00","150","","","Percent of Total Billed Charges","neg_dollar:$4461.90;150% of Medicaid interim rate","2308.80","80","","","Percent of Total Billed Charges","neg_dollar:$2308.80;Percent of Total Billed Charges","","","","2886.00","Fee Schedule","","1500.72","52","","","Percent of Total Billed Charges","neg_dollar:$1500.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1500.72","52","","","Percent of Total Billed Charges","neg_dollar:$1500.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2886.00",""
"SOFT TISSUE NECK","70360","CPT","70000014","CDM","320","RC","","Facility","Outpatient","","","271","216.80","271.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","140.92","52","","","Percent of Total Billed Charges","neg_dollar:$140.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","271.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","140.92","52","","","Percent of Total Billed Charges","neg_dollar:$140.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","140.92","52","","","Percent of Total Billed Charges","neg_dollar:$140.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","140.92","52","","","Percent of Total Billed Charges","neg_dollar:$140.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","233.06","86","","","Percent of Total Billed Charges","neg_dollar:$233.06","189.70","70","","","Percent of Total Billed Charges","neg_dollar:$189.70","140.92","52","","","Percent of Total Billed Charges","neg_dollar:$140.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","159.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$159.21;102% of Medicaid interim rate","203.25","75","","","Percent of Total Billed Charges","neg_dollar:$203.25","233.06","86","","","Percent of Total Billed Charges","neg_dollar:$233.06","189.70","70","","","Percent of Total Billed Charges","neg_dollar:$189.70","154.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$154.47;103.5% of Medicaid interim rate","271.00","150","","","Percent of Total Billed Charges","neg_dollar:$418.97;150% of Medicaid interim rate","216.80","80","","","Percent of Total Billed Charges","neg_dollar:$216.80;Percent of Total Billed Charges","","","","271.00","Fee Schedule","","140.92","52","","","Percent of Total Billed Charges","neg_dollar:$140.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","140.92","52","","","Percent of Total Billed Charges","neg_dollar:$140.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","140.00","271.00",""
"CT HEAD OR BRAIN WO CONTRAST","70450","CPT","70000016","CDM","351","RC","","Facility","Outpatient","","","2314","1851.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1203.28","52","","","Percent of Total Billed Charges","neg_dollar:$1203.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1203.28","52","","","Percent of Total Billed Charges","neg_dollar:$1203.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","1203.28","52","","","Percent of Total Billed Charges","neg_dollar:$1203.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","1203.28","52","","","Percent of Total Billed Charges","neg_dollar:$1203.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","1990.04","86","","","Percent of Total Billed Charges","neg_dollar:$1990.04","1619.80","70","","","Percent of Total Billed Charges","neg_dollar:$1619.80","1203.28","52","","","Percent of Total Billed Charges","neg_dollar:$1203.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","1359.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$1359.47;102% of Medicaid interim rate","1735.50","75","","","Percent of Total Billed Charges","neg_dollar:$1735.50","1990.04","86","","","Percent of Total Billed Charges","neg_dollar:$1990.04","1619.80","70","","","Percent of Total Billed Charges","neg_dollar:$1619.80","1318.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$1318.97;103.5% of Medicaid interim rate","2314.00","150","","","Percent of Total Billed Charges","neg_dollar:$3577.55;150% of Medicaid interim rate","1851.20","80","","","Percent of Total Billed Charges","neg_dollar:$1851.20;Percent of Total Billed Charges","","","","1154.00","Fee Schedule","","1203.28","52","","","Percent of Total Billed Charges","neg_dollar:$1203.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","1203.28","52","","","Percent of Total Billed Charges","neg_dollar:$1203.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2314.00",""
"CT HEAD OR BRAIN W CONTRAST","70460","CPT","70000017","CDM","351","RC","","Facility","Outpatient","","","2968","2374.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1543.36","52","","","Percent of Total Billed Charges","neg_dollar:$1543.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1543.36","52","","","Percent of Total Billed Charges","neg_dollar:$1543.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1543.36","52","","","Percent of Total Billed Charges","neg_dollar:$1543.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1543.36","52","","","Percent of Total Billed Charges","neg_dollar:$1543.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","2552.48","86","","","Percent of Total Billed Charges","neg_dollar:$2552.48","2077.60","70","","","Percent of Total Billed Charges","neg_dollar:$2077.60","1543.36","52","","","Percent of Total Billed Charges","neg_dollar:$1543.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","1743.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$1743.69;102% of Medicaid interim rate","2226.00","75","","","Percent of Total Billed Charges","neg_dollar:$2226","2552.48","86","","","Percent of Total Billed Charges","neg_dollar:$2552.48","2077.60","70","","","Percent of Total Billed Charges","neg_dollar:$2077.60","1691.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$1691.75;103.5% of Medicaid interim rate","2968.00","150","","","Percent of Total Billed Charges","neg_dollar:$4588.67;150% of Medicaid interim rate","2374.40","80","","","Percent of Total Billed Charges","neg_dollar:$2374.40;Percent of Total Billed Charges","","","","2968.00","Fee Schedule","","1543.36","52","","","Percent of Total Billed Charges","neg_dollar:$1543.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","1543.36","52","","","Percent of Total Billed Charges","neg_dollar:$1543.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2968.00",""
"CT HEAD OR BRAIN W WO CONTRAST","70470","CPT","70000018","CDM","351","RC","","Facility","Outpatient","","","3240","2592.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1684.80","52","","","Percent of Total Billed Charges","neg_dollar:$1684.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1684.80","52","","","Percent of Total Billed Charges","neg_dollar:$1684.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1684.80","52","","","Percent of Total Billed Charges","neg_dollar:$1684.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1684.80","52","","","Percent of Total Billed Charges","neg_dollar:$1684.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2786.40","86","","","Percent of Total Billed Charges","neg_dollar:$2786.40","2268.00","70","","","Percent of Total Billed Charges","neg_dollar:$2268","1684.80","52","","","Percent of Total Billed Charges","neg_dollar:$1684.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","1903.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$1903.49;102% of Medicaid interim rate","2430.00","75","","","Percent of Total Billed Charges","neg_dollar:$2430","2786.40","86","","","Percent of Total Billed Charges","neg_dollar:$2786.40","2268.00","70","","","Percent of Total Billed Charges","neg_dollar:$2268","1846.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$1846.80;103.5% of Medicaid interim rate","3240.00","150","","","Percent of Total Billed Charges","neg_dollar:$5009.20;150% of Medicaid interim rate","2592.00","80","","","Percent of Total Billed Charges","neg_dollar:$2592;Percent of Total Billed Charges","","","","3240.00","Fee Schedule","","1684.80","52","","","Percent of Total Billed Charges","neg_dollar:$1684.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1684.80","52","","","Percent of Total Billed Charges","neg_dollar:$1684.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3240.00",""
"CT ORBIT SELLA MID INNER EAR WO CONTR","70480","CPT","70000019","CDM","351","RC","","Facility","Outpatient","","","2036","1628.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1058.72","52","","","Percent of Total Billed Charges","neg_dollar:$1058.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1058.72","52","","","Percent of Total Billed Charges","neg_dollar:$1058.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1058.72","52","","","Percent of Total Billed Charges","neg_dollar:$1058.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1058.72","52","","","Percent of Total Billed Charges","neg_dollar:$1058.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1750.96","86","","","Percent of Total Billed Charges","neg_dollar:$1750.96","1425.19","70","","","Percent of Total Billed Charges","neg_dollar:$1425.19","1058.72","52","","","Percent of Total Billed Charges","neg_dollar:$1058.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","1196.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1196.14;102% of Medicaid interim rate","1527.00","75","","","Percent of Total Billed Charges","neg_dollar:$1527","1750.96","86","","","Percent of Total Billed Charges","neg_dollar:$1750.96","1425.19","70","","","Percent of Total Billed Charges","neg_dollar:$1425.19","1160.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$1160.52;103.5% of Medicaid interim rate","2036.00","150","","","Percent of Total Billed Charges","neg_dollar:$3147.75;150% of Medicaid interim rate","1628.80","80","","","Percent of Total Billed Charges","neg_dollar:$1628.80;Percent of Total Billed Charges","","","","2036.00","Fee Schedule","","1058.72","52","","","Percent of Total Billed Charges","neg_dollar:$1058.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1058.72","52","","","Percent of Total Billed Charges","neg_dollar:$1058.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2036.00",""
"CT ORBIT SELLA MID INNER EAR W CONTR","70481","CPT","70000020","CDM","351","RC","","Facility","Outpatient","","","2499","1999.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1299.48","52","","","Percent of Total Billed Charges","neg_dollar:$1299.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1299.48","52","","","Percent of Total Billed Charges","neg_dollar:$1299.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1299.48","52","","","Percent of Total Billed Charges","neg_dollar:$1299.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1299.48","52","","","Percent of Total Billed Charges","neg_dollar:$1299.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2149.14","86","","","Percent of Total Billed Charges","neg_dollar:$2149.14","1749.30","70","","","Percent of Total Billed Charges","neg_dollar:$1749.30","1299.48","52","","","Percent of Total Billed Charges","neg_dollar:$1299.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","1468.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1468.16;102% of Medicaid interim rate","1874.25","75","","","Percent of Total Billed Charges","neg_dollar:$1874.25","2149.14","86","","","Percent of Total Billed Charges","neg_dollar:$2149.14","1749.30","70","","","Percent of Total Billed Charges","neg_dollar:$1749.30","1424.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$1424.42;103.5% of Medicaid interim rate","2499.00","150","","","Percent of Total Billed Charges","neg_dollar:$3863.57;150% of Medicaid interim rate","1999.20","80","","","Percent of Total Billed Charges","neg_dollar:$1999.20;Percent of Total Billed Charges","","","","2499.00","Fee Schedule","","1299.48","52","","","Percent of Total Billed Charges","neg_dollar:$1299.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1299.48","52","","","Percent of Total Billed Charges","neg_dollar:$1299.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2499.00",""
"CT ORBIT SELLA MID INNER EAR W WO CONTR","70482","CPT","70000021","CDM","351","RC","","Facility","Outpatient","","","2962","2369.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1540.24","52","","","Percent of Total Billed Charges","neg_dollar:$1540.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1540.24","52","","","Percent of Total Billed Charges","neg_dollar:$1540.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1540.24","52","","","Percent of Total Billed Charges","neg_dollar:$1540.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1540.24","52","","","Percent of Total Billed Charges","neg_dollar:$1540.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2547.32","86","","","Percent of Total Billed Charges","neg_dollar:$2547.32","2073.40","70","","","Percent of Total Billed Charges","neg_dollar:$2073.40","1540.24","52","","","Percent of Total Billed Charges","neg_dollar:$1540.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","1740.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1740.17;102% of Medicaid interim rate","2221.50","75","","","Percent of Total Billed Charges","neg_dollar:$2221.50","2547.32","86","","","Percent of Total Billed Charges","neg_dollar:$2547.32","2073.40","70","","","Percent of Total Billed Charges","neg_dollar:$2073.40","1688.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$1688.34;103.5% of Medicaid interim rate","2962.00","150","","","Percent of Total Billed Charges","neg_dollar:$4579.40;150% of Medicaid interim rate","2369.60","80","","","Percent of Total Billed Charges","neg_dollar:$2369.60;Percent of Total Billed Charges","","","","2962.00","Fee Schedule","","1540.24","52","","","Percent of Total Billed Charges","neg_dollar:$1540.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1540.24","52","","","Percent of Total Billed Charges","neg_dollar:$1540.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2962.00",""
"CT MAXILLOFACIAL WO CONTRAST","70486","CPT","70000022","CDM","351","RC","","Facility","Outpatient","","","2282","1825.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1186.64","52","","","Percent of Total Billed Charges","neg_dollar:$1186.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1186.64","52","","","Percent of Total Billed Charges","neg_dollar:$1186.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1186.64","52","","","Percent of Total Billed Charges","neg_dollar:$1186.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1186.64","52","","","Percent of Total Billed Charges","neg_dollar:$1186.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1962.52","86","","","Percent of Total Billed Charges","neg_dollar:$1962.52","1597.39","70","","","Percent of Total Billed Charges","neg_dollar:$1597.39","1186.64","52","","","Percent of Total Billed Charges","neg_dollar:$1186.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","1340.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$1340.67;102% of Medicaid interim rate","1711.50","75","","","Percent of Total Billed Charges","neg_dollar:$1711.50","1962.52","86","","","Percent of Total Billed Charges","neg_dollar:$1962.52","1597.39","70","","","Percent of Total Billed Charges","neg_dollar:$1597.39","1300.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$1300.73;103.5% of Medicaid interim rate","2282.00","150","","","Percent of Total Billed Charges","neg_dollar:$3528.08;150% of Medicaid interim rate","1825.60","80","","","Percent of Total Billed Charges","neg_dollar:$1825.60;Percent of Total Billed Charges","","","","1812.00","Fee Schedule","","1186.64","52","","","Percent of Total Billed Charges","neg_dollar:$1186.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","1186.64","52","","","Percent of Total Billed Charges","neg_dollar:$1186.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2282.00",""
"CT MAXILLOFACIAL W CONTRAST","70487","CPT","70000023","CDM","351","RC","","Facility","Outpatient","","","2746","2196.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1427.92","52","","","Percent of Total Billed Charges","neg_dollar:$1427.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1427.92","52","","","Percent of Total Billed Charges","neg_dollar:$1427.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1427.92","52","","","Percent of Total Billed Charges","neg_dollar:$1427.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1427.92","52","","","Percent of Total Billed Charges","neg_dollar:$1427.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2361.56","86","","","Percent of Total Billed Charges","neg_dollar:$2361.56","1922.19","70","","","Percent of Total Billed Charges","neg_dollar:$1922.19","1427.92","52","","","Percent of Total Billed Charges","neg_dollar:$1427.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","1613.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$1613.27;102% of Medicaid interim rate","2059.50","75","","","Percent of Total Billed Charges","neg_dollar:$2059.50","2361.56","86","","","Percent of Total Billed Charges","neg_dollar:$2361.56","1922.19","70","","","Percent of Total Billed Charges","neg_dollar:$1922.19","1565.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$1565.21;103.5% of Medicaid interim rate","2746.00","150","","","Percent of Total Billed Charges","neg_dollar:$4245.45;150% of Medicaid interim rate","2196.80","80","","","Percent of Total Billed Charges","neg_dollar:$2196.80;Percent of Total Billed Charges","","","","1838.00","Fee Schedule","","1427.92","52","","","Percent of Total Billed Charges","neg_dollar:$1427.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","1427.92","52","","","Percent of Total Billed Charges","neg_dollar:$1427.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2746.00",""
"CT MAXILLOFACIAL W WO CONTRAST","70488","CPT","70000024","CDM","351","RC","","Facility","Outpatient","","","3208","2566.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1668.16","52","","","Percent of Total Billed Charges","neg_dollar:$1668.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1668.16","52","","","Percent of Total Billed Charges","neg_dollar:$1668.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1668.16","52","","","Percent of Total Billed Charges","neg_dollar:$1668.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1668.16","52","","","Percent of Total Billed Charges","neg_dollar:$1668.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","2758.88","86","","","Percent of Total Billed Charges","neg_dollar:$2758.88","2245.60","70","","","Percent of Total Billed Charges","neg_dollar:$2245.60","1668.16","52","","","Percent of Total Billed Charges","neg_dollar:$1668.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","1884.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$1884.69;102% of Medicaid interim rate","2406.00","75","","","Percent of Total Billed Charges","neg_dollar:$2406","2758.88","86","","","Percent of Total Billed Charges","neg_dollar:$2758.88","2245.60","70","","","Percent of Total Billed Charges","neg_dollar:$2245.60","1828.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$1828.56;103.5% of Medicaid interim rate","3208.00","150","","","Percent of Total Billed Charges","neg_dollar:$4959.72;150% of Medicaid interim rate","2566.40","80","","","Percent of Total Billed Charges","neg_dollar:$2566.40;Percent of Total Billed Charges","","","","3208.00","Fee Schedule","","1668.16","52","","","Percent of Total Billed Charges","neg_dollar:$1668.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","1668.16","52","","","Percent of Total Billed Charges","neg_dollar:$1668.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3208.00",""
"CT SOFT TISSUE NECK WO CONTRAST","70490","CPT","70000025","CDM","351","RC","","Facility","Outpatient","","","2437","1949.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1267.24","52","","","Percent of Total Billed Charges","neg_dollar:$1267.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1267.24","52","","","Percent of Total Billed Charges","neg_dollar:$1267.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1267.24","52","","","Percent of Total Billed Charges","neg_dollar:$1267.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1267.24","52","","","Percent of Total Billed Charges","neg_dollar:$1267.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2095.82","86","","","Percent of Total Billed Charges","neg_dollar:$2095.82","1705.89","70","","","Percent of Total Billed Charges","neg_dollar:$1705.89","1267.24","52","","","Percent of Total Billed Charges","neg_dollar:$1267.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","1431.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$1431.73;102% of Medicaid interim rate","1827.75","75","","","Percent of Total Billed Charges","neg_dollar:$1827.75","2095.82","86","","","Percent of Total Billed Charges","neg_dollar:$2095.82","1705.89","70","","","Percent of Total Billed Charges","neg_dollar:$1705.89","1389.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$1389.09;103.5% of Medicaid interim rate","2437.00","150","","","Percent of Total Billed Charges","neg_dollar:$3767.72;150% of Medicaid interim rate","1949.60","80","","","Percent of Total Billed Charges","neg_dollar:$1949.60;Percent of Total Billed Charges","","","","1631.00","Fee Schedule","","1267.24","52","","","Percent of Total Billed Charges","neg_dollar:$1267.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1267.24","52","","","Percent of Total Billed Charges","neg_dollar:$1267.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2437.00",""
"CT SOFT TISSUE NECK W CONTRAST","70491","CPT","70000026","CDM","351","RC","","Facility","Outpatient","","","3005","2404.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1562.60","52","","","Percent of Total Billed Charges","neg_dollar:$1562.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1562.60","52","","","Percent of Total Billed Charges","neg_dollar:$1562.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","1562.60","52","","","Percent of Total Billed Charges","neg_dollar:$1562.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","1562.60","52","","","Percent of Total Billed Charges","neg_dollar:$1562.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","2584.30","86","","","Percent of Total Billed Charges","neg_dollar:$2584.30","2103.50","70","","","Percent of Total Billed Charges","neg_dollar:$2103.50","1562.60","52","","","Percent of Total Billed Charges","neg_dollar:$1562.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","1765.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$1765.43;102% of Medicaid interim rate","2253.75","75","","","Percent of Total Billed Charges","neg_dollar:$2253.75","2584.30","86","","","Percent of Total Billed Charges","neg_dollar:$2584.30","2103.50","70","","","Percent of Total Billed Charges","neg_dollar:$2103.50","1712.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$1712.85;103.5% of Medicaid interim rate","3005.00","150","","","Percent of Total Billed Charges","neg_dollar:$4645.88;150% of Medicaid interim rate","2404.00","80","","","Percent of Total Billed Charges","neg_dollar:$2404;Percent of Total Billed Charges","","","","1463.00","Fee Schedule","","1562.60","52","","","Percent of Total Billed Charges","neg_dollar:$1562.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1562.60","52","","","Percent of Total Billed Charges","neg_dollar:$1562.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3005.00",""
"CT SOFT TISSUE NECK W WO CONTRAST","70492","CPT","70000027","CDM","351","RC","","Facility","Outpatient","","","3468","2774.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1803.36","52","","","Percent of Total Billed Charges","neg_dollar:$1803.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1803.36","52","","","Percent of Total Billed Charges","neg_dollar:$1803.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1803.36","52","","","Percent of Total Billed Charges","neg_dollar:$1803.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1803.36","52","","","Percent of Total Billed Charges","neg_dollar:$1803.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","2982.48","86","","","Percent of Total Billed Charges","neg_dollar:$2982.48","2427.60","70","","","Percent of Total Billed Charges","neg_dollar:$2427.60","1803.36","52","","","Percent of Total Billed Charges","neg_dollar:$1803.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","2037.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$2037.44;102% of Medicaid interim rate","2601.00","75","","","Percent of Total Billed Charges","neg_dollar:$2601","2982.48","86","","","Percent of Total Billed Charges","neg_dollar:$2982.48","2427.60","70","","","Percent of Total Billed Charges","neg_dollar:$2427.60","1976.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$1976.75;103.5% of Medicaid interim rate","3468.00","150","","","Percent of Total Billed Charges","neg_dollar:$5361.70;150% of Medicaid interim rate","2774.40","80","","","Percent of Total Billed Charges","neg_dollar:$2774.40;Percent of Total Billed Charges","","","","3468.00","Fee Schedule","","1803.36","52","","","Percent of Total Billed Charges","neg_dollar:$1803.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","1803.36","52","","","Percent of Total Billed Charges","neg_dollar:$1803.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3468.00",""
"CT ANGIOGRAPHY HEAD W WO CONTRAST","70496","CPT","70000028","CDM","351","RC","","Facility","Outpatient","","","2957","2365.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2543.02","86","","","Percent of Total Billed Charges","neg_dollar:$2543.02","2069.90","70","","","Percent of Total Billed Charges","neg_dollar:$2069.90","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","1737.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1737.23;102% of Medicaid interim rate","2217.75","75","","","Percent of Total Billed Charges","neg_dollar:$2217.75","2543.02","86","","","Percent of Total Billed Charges","neg_dollar:$2543.02","2069.90","70","","","Percent of Total Billed Charges","neg_dollar:$2069.90","1685.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1685.48;103.5% of Medicaid interim rate","2957.00","150","","","Percent of Total Billed Charges","neg_dollar:$4571.66;150% of Medicaid interim rate","2365.60","80","","","Percent of Total Billed Charges","neg_dollar:$2365.60;Percent of Total Billed Charges","","","","2029.00","Fee Schedule","","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2957.00",""
"CT ANGIOGRAPHY NECK W WO CONTRAST","70498","CPT","70000029","CDM","351","RC","","Facility","Outpatient","","","3238","2590.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1683.76","52","","","Percent of Total Billed Charges","neg_dollar:$1683.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1683.76","52","","","Percent of Total Billed Charges","neg_dollar:$1683.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1683.76","52","","","Percent of Total Billed Charges","neg_dollar:$1683.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1683.76","52","","","Percent of Total Billed Charges","neg_dollar:$1683.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2784.68","86","","","Percent of Total Billed Charges","neg_dollar:$2784.68","2266.60","70","","","Percent of Total Billed Charges","neg_dollar:$2266.60","1683.76","52","","","Percent of Total Billed Charges","neg_dollar:$1683.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","1902.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$1902.32;102% of Medicaid interim rate","2428.50","75","","","Percent of Total Billed Charges","neg_dollar:$2428.50","2784.68","86","","","Percent of Total Billed Charges","neg_dollar:$2784.68","2266.60","70","","","Percent of Total Billed Charges","neg_dollar:$2266.60","1845.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$1845.65;103.5% of Medicaid interim rate","3238.00","150","","","Percent of Total Billed Charges","neg_dollar:$5006.10;150% of Medicaid interim rate","2590.40","80","","","Percent of Total Billed Charges","neg_dollar:$2590.40;Percent of Total Billed Charges","","","","2277.00","Fee Schedule","","1683.76","52","","","Percent of Total Billed Charges","neg_dollar:$1683.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1683.76","52","","","Percent of Total Billed Charges","neg_dollar:$1683.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3238.00",""
"MRI ORBIT FACE NECK WO CONTRAST","70540","CPT","70000030","CDM","610","RC","","Facility","Outpatient","","","3469","2775.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2983.34","86","","","Percent of Total Billed Charges","neg_dollar:$2983.34","2428.29","70","","","Percent of Total Billed Charges","neg_dollar:$2428.29","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","2038.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$2038.03;102% of Medicaid interim rate","2601.75","75","","","Percent of Total Billed Charges","neg_dollar:$2601.75","2983.34","86","","","Percent of Total Billed Charges","neg_dollar:$2983.34","2428.29","70","","","Percent of Total Billed Charges","neg_dollar:$2428.29","1977.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$1977.33;103.5% of Medicaid interim rate","3469.00","150","","","Percent of Total Billed Charges","neg_dollar:$5363.24;150% of Medicaid interim rate","2775.20","80","","","Percent of Total Billed Charges","neg_dollar:$2775.20;Percent of Total Billed Charges","","","","3469.00","Fee Schedule","","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3469.00",""
"MRI ORBIT FACE NECK W CONTRAST","70542","CPT","70000031","CDM","610","RC","","Facility","Outpatient","","","3932","3145.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2044.64","52","","","Percent of Total Billed Charges","neg_dollar:$2044.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2044.64","52","","","Percent of Total Billed Charges","neg_dollar:$2044.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2044.64","52","","","Percent of Total Billed Charges","neg_dollar:$2044.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2044.64","52","","","Percent of Total Billed Charges","neg_dollar:$2044.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","3381.52","86","","","Percent of Total Billed Charges","neg_dollar:$3381.52","2752.39","70","","","Percent of Total Billed Charges","neg_dollar:$2752.39","2044.64","52","","","Percent of Total Billed Charges","neg_dollar:$2044.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","2310.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$2310.04;102% of Medicaid interim rate","2949.00","75","","","Percent of Total Billed Charges","neg_dollar:$2949","3381.52","86","","","Percent of Total Billed Charges","neg_dollar:$3381.52","2752.39","70","","","Percent of Total Billed Charges","neg_dollar:$2752.39","2241.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$2241.24;103.5% of Medicaid interim rate","3932.00","150","","","Percent of Total Billed Charges","neg_dollar:$6079.06;150% of Medicaid interim rate","3145.60","80","","","Percent of Total Billed Charges","neg_dollar:$3145.60;Percent of Total Billed Charges","","","","3932.00","Fee Schedule","","2044.64","52","","","Percent of Total Billed Charges","neg_dollar:$2044.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","2044.64","52","","","Percent of Total Billed Charges","neg_dollar:$2044.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3932.00",""
"MRI ORBIT FACE NECK W WO CONTRAST","70543","CPT","70000032","CDM","610","RC","","Facility","Outpatient","","","5011","4008.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2605.72","52","","","Percent of Total Billed Charges","neg_dollar:$2605.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2605.72","52","","","Percent of Total Billed Charges","neg_dollar:$2605.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","2605.72","52","","","Percent of Total Billed Charges","neg_dollar:$2605.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","2605.72","52","","","Percent of Total Billed Charges","neg_dollar:$2605.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","4309.46","86","","","Percent of Total Billed Charges","neg_dollar:$4309.46","3507.70","70","","","Percent of Total Billed Charges","neg_dollar:$3507.70","2605.72","52","","","Percent of Total Billed Charges","neg_dollar:$2605.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","2943.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$2943.95;102% of Medicaid interim rate","3758.25","75","","","Percent of Total Billed Charges","neg_dollar:$3758.25","4309.46","86","","","Percent of Total Billed Charges","neg_dollar:$4309.46","3507.70","70","","","Percent of Total Billed Charges","neg_dollar:$3507.70","2856.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$2856.27;103.5% of Medicaid interim rate","5011.00","150","","","Percent of Total Billed Charges","neg_dollar:$7747.25;150% of Medicaid interim rate","4008.80","80","","","Percent of Total Billed Charges","neg_dollar:$4008.80;Percent of Total Billed Charges","","","","3354.00","Fee Schedule","","2605.72","52","","","Percent of Total Billed Charges","neg_dollar:$2605.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","2605.72","52","","","Percent of Total Billed Charges","neg_dollar:$2605.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5011.00",""
"MRA HEAD WO CONTRAST","70544","CPT","70000033","CDM","615","RC","","Facility","Outpatient","","","3469","2775.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2983.34","86","","","Percent of Total Billed Charges","neg_dollar:$2983.34","2428.29","70","","","Percent of Total Billed Charges","neg_dollar:$2428.29","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","2038.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$2038.03;102% of Medicaid interim rate","2601.75","75","","","Percent of Total Billed Charges","neg_dollar:$2601.75","2983.34","86","","","Percent of Total Billed Charges","neg_dollar:$2983.34","2428.29","70","","","Percent of Total Billed Charges","neg_dollar:$2428.29","1977.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$1977.33;103.5% of Medicaid interim rate","3469.00","150","","","Percent of Total Billed Charges","neg_dollar:$5363.24;150% of Medicaid interim rate","2775.20","80","","","Percent of Total Billed Charges","neg_dollar:$2775.20;Percent of Total Billed Charges","3191.48","92","","","Percent of Total Billed Charges","neg_dollar:$3191.48","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1803.88","52","","","Percent of Total Billed Charges","neg_dollar:$1803.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3469.00",""
"MRA HEAD W CONTRAST","70545","CPT","70000034","CDM","615","RC","","Facility","Outpatient","","","4402","3521.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2289.04","52","","","Percent of Total Billed Charges","neg_dollar:$2289.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2289.04","52","","","Percent of Total Billed Charges","neg_dollar:$2289.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2289.04","52","","","Percent of Total Billed Charges","neg_dollar:$2289.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2289.04","52","","","Percent of Total Billed Charges","neg_dollar:$2289.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","3785.72","86","","","Percent of Total Billed Charges","neg_dollar:$3785.72","3081.39","70","","","Percent of Total Billed Charges","neg_dollar:$3081.39","2289.04","52","","","Percent of Total Billed Charges","neg_dollar:$2289.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","2586.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$2586.17;102% of Medicaid interim rate","3301.50","75","","","Percent of Total Billed Charges","neg_dollar:$3301.50","3785.72","86","","","Percent of Total Billed Charges","neg_dollar:$3785.72","3081.39","70","","","Percent of Total Billed Charges","neg_dollar:$3081.39","2509.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$2509.14;103.5% of Medicaid interim rate","4402.00","150","","","Percent of Total Billed Charges","neg_dollar:$6805.71;150% of Medicaid interim rate","3521.60","80","","","Percent of Total Billed Charges","neg_dollar:$3521.60;Percent of Total Billed Charges","4049.84","92","","","Percent of Total Billed Charges","neg_dollar:$4049.84","2289.04","52","","","Percent of Total Billed Charges","neg_dollar:$2289.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","2289.04","52","","","Percent of Total Billed Charges","neg_dollar:$2289.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4402.00",""
"MRA HEAD W WO CONTRAST","70546","CPT","70000035","CDM","615","RC","","Facility","Outpatient","","","5313","4250.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2762.76","52","","","Percent of Total Billed Charges","neg_dollar:$2762.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2762.76","52","","","Percent of Total Billed Charges","neg_dollar:$2762.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2762.76","52","","","Percent of Total Billed Charges","neg_dollar:$2762.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2762.76","52","","","Percent of Total Billed Charges","neg_dollar:$2762.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","4569.18","86","","","Percent of Total Billed Charges","neg_dollar:$4569.18","3719.10","70","","","Percent of Total Billed Charges","neg_dollar:$3719.10","2762.76","52","","","Percent of Total Billed Charges","neg_dollar:$2762.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","3121.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$3121.38;102% of Medicaid interim rate","3984.75","75","","","Percent of Total Billed Charges","neg_dollar:$3984.75","4569.18","86","","","Percent of Total Billed Charges","neg_dollar:$4569.18","3719.10","70","","","Percent of Total Billed Charges","neg_dollar:$3719.10","3028.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$3028.41;103.5% of Medicaid interim rate","5313.00","150","","","Percent of Total Billed Charges","neg_dollar:$8214.16;150% of Medicaid interim rate","4250.40","80","","","Percent of Total Billed Charges","neg_dollar:$4250.40;Percent of Total Billed Charges","4887.96","92","","","Percent of Total Billed Charges","neg_dollar:$4887.96","2762.76","52","","","Percent of Total Billed Charges","neg_dollar:$2762.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","2762.76","52","","","Percent of Total Billed Charges","neg_dollar:$2762.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5313.00",""
"MRA NECK WO CONTRAST","70547","CPT","70000036","CDM","615","RC","","Facility","Outpatient","","","3549","2839.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1845.48","52","","","Percent of Total Billed Charges","neg_dollar:$1845.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1845.48","52","","","Percent of Total Billed Charges","neg_dollar:$1845.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1845.48","52","","","Percent of Total Billed Charges","neg_dollar:$1845.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1845.48","52","","","Percent of Total Billed Charges","neg_dollar:$1845.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","3052.14","86","","","Percent of Total Billed Charges","neg_dollar:$3052.14","2484.29","70","","","Percent of Total Billed Charges","neg_dollar:$2484.29","1845.48","52","","","Percent of Total Billed Charges","neg_dollar:$1845.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","2085.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$2085.03;102% of Medicaid interim rate","2661.75","75","","","Percent of Total Billed Charges","neg_dollar:$2661.75","3052.14","86","","","Percent of Total Billed Charges","neg_dollar:$3052.14","2484.29","70","","","Percent of Total Billed Charges","neg_dollar:$2484.29","2022.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$2022.92;103.5% of Medicaid interim rate","3549.00","150","","","Percent of Total Billed Charges","neg_dollar:$5486.93;150% of Medicaid interim rate","2839.20","80","","","Percent of Total Billed Charges","neg_dollar:$2839.20;Percent of Total Billed Charges","3265.08","92","","","Percent of Total Billed Charges","neg_dollar:$3265.08","1845.48","52","","","Percent of Total Billed Charges","neg_dollar:$1845.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1845.48","52","","","Percent of Total Billed Charges","neg_dollar:$1845.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3549.00",""
"MRA NECK W CONTRAST","70548","CPT","70000037","CDM","615","RC","","Facility","Outpatient","","","4012","3209.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2086.24","52","","","Percent of Total Billed Charges","neg_dollar:$2086.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2086.24","52","","","Percent of Total Billed Charges","neg_dollar:$2086.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2086.24","52","","","Percent of Total Billed Charges","neg_dollar:$2086.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2086.24","52","","","Percent of Total Billed Charges","neg_dollar:$2086.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","3450.32","86","","","Percent of Total Billed Charges","neg_dollar:$3450.32","2808.39","70","","","Percent of Total Billed Charges","neg_dollar:$2808.39","2086.24","52","","","Percent of Total Billed Charges","neg_dollar:$2086.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","2357.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$2357.04;102% of Medicaid interim rate","3009.00","75","","","Percent of Total Billed Charges","neg_dollar:$3009","3450.32","86","","","Percent of Total Billed Charges","neg_dollar:$3450.32","2808.39","70","","","Percent of Total Billed Charges","neg_dollar:$2808.39","2286.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$2286.83;103.5% of Medicaid interim rate","4012.00","150","","","Percent of Total Billed Charges","neg_dollar:$6202.75;150% of Medicaid interim rate","3209.60","80","","","Percent of Total Billed Charges","neg_dollar:$3209.60;Percent of Total Billed Charges","3691.04","92","","","Percent of Total Billed Charges","neg_dollar:$3691.04","2086.24","52","","","Percent of Total Billed Charges","neg_dollar:$2086.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","2086.24","52","","","Percent of Total Billed Charges","neg_dollar:$2086.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4012.00",""
"MRA NECK W WO CONTRAST","70549","CPT","70000038","CDM","615","RC","","Facility","Outpatient","","","5446","4356.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2831.92","52","","","Percent of Total Billed Charges","neg_dollar:$2831.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2831.92","52","","","Percent of Total Billed Charges","neg_dollar:$2831.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2831.92","52","","","Percent of Total Billed Charges","neg_dollar:$2831.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2831.92","52","","","Percent of Total Billed Charges","neg_dollar:$2831.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","4683.55","86","","","Percent of Total Billed Charges","neg_dollar:$4683.55","3812.20","70","","","Percent of Total Billed Charges","neg_dollar:$3812.20","2831.92","52","","","Percent of Total Billed Charges","neg_dollar:$2831.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","3199.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$3199.51;102% of Medicaid interim rate","4084.50","75","","","Percent of Total Billed Charges","neg_dollar:$4084.50","4683.55","86","","","Percent of Total Billed Charges","neg_dollar:$4683.55","3812.20","70","","","Percent of Total Billed Charges","neg_dollar:$3812.20","3104.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$3104.22;103.5% of Medicaid interim rate","5446.00","150","","","Percent of Total Billed Charges","neg_dollar:$8419.78;150% of Medicaid interim rate","4356.80","80","","","Percent of Total Billed Charges","neg_dollar:$4356.80;Percent of Total Billed Charges","5010.32","92","","","Percent of Total Billed Charges","neg_dollar:$5010.32","2831.92","52","","","Percent of Total Billed Charges","neg_dollar:$2831.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","2831.92","52","","","Percent of Total Billed Charges","neg_dollar:$2831.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5446.00",""
"MRI BRAIN WO CONTRAST","70551","CPT","70000039","CDM","611","RC","","Facility","Outpatient","","","3866","3092.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2010.32","52","","","Percent of Total Billed Charges","neg_dollar:$2010.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2010.32","52","","","Percent of Total Billed Charges","neg_dollar:$2010.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","2010.32","52","","","Percent of Total Billed Charges","neg_dollar:$2010.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","2010.32","52","","","Percent of Total Billed Charges","neg_dollar:$2010.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","3324.75","86","","","Percent of Total Billed Charges","neg_dollar:$3324.75","2706.20","70","","","Percent of Total Billed Charges","neg_dollar:$2706.20","2010.32","52","","","Percent of Total Billed Charges","neg_dollar:$2010.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","2271.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$2271.27;102% of Medicaid interim rate","2899.50","75","","","Percent of Total Billed Charges","neg_dollar:$2899.50","3324.75","86","","","Percent of Total Billed Charges","neg_dollar:$3324.75","2706.20","70","","","Percent of Total Billed Charges","neg_dollar:$2706.20","2203.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2203.62;103.5% of Medicaid interim rate","3866.00","150","","","Percent of Total Billed Charges","neg_dollar:$5977.02;150% of Medicaid interim rate","3092.80","80","","","Percent of Total Billed Charges","neg_dollar:$3092.80;Percent of Total Billed Charges","","","","1836.00","Fee Schedule","","2010.32","52","","","Percent of Total Billed Charges","neg_dollar:$2010.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","2010.32","52","","","Percent of Total Billed Charges","neg_dollar:$2010.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3866.00",""
"MRI BRAIN W CONTRAST","70552","CPT","70000040","CDM","611","RC","","Facility","Outpatient","","","4329","3463.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2251.08","52","","","Percent of Total Billed Charges","neg_dollar:$2251.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2251.08","52","","","Percent of Total Billed Charges","neg_dollar:$2251.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","2251.08","52","","","Percent of Total Billed Charges","neg_dollar:$2251.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","2251.08","52","","","Percent of Total Billed Charges","neg_dollar:$2251.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","3722.94","86","","","Percent of Total Billed Charges","neg_dollar:$3722.94","3030.29","70","","","Percent of Total Billed Charges","neg_dollar:$3030.29","2251.08","52","","","Percent of Total Billed Charges","neg_dollar:$2251.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","2543.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$2543.28;102% of Medicaid interim rate","3246.75","75","","","Percent of Total Billed Charges","neg_dollar:$3246.75","3722.94","86","","","Percent of Total Billed Charges","neg_dollar:$3722.94","3030.29","70","","","Percent of Total Billed Charges","neg_dollar:$3030.29","2467.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$2467.52;103.5% of Medicaid interim rate","4329.00","150","","","Percent of Total Billed Charges","neg_dollar:$6692.85;150% of Medicaid interim rate","3463.20","80","","","Percent of Total Billed Charges","neg_dollar:$3463.20;Percent of Total Billed Charges","","","","2810.00","Fee Schedule","","2251.08","52","","","Percent of Total Billed Charges","neg_dollar:$2251.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2251.08","52","","","Percent of Total Billed Charges","neg_dollar:$2251.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4329.00",""
"MRI BRAIN W WO CONTRAST","70553","CPT","70000041","CDM","611","RC","","Facility","Outpatient","","","6172","4937.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","3209.44","52","","","Percent of Total Billed Charges","neg_dollar:$3209.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","3209.44","52","","","Percent of Total Billed Charges","neg_dollar:$3209.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","3209.44","52","","","Percent of Total Billed Charges","neg_dollar:$3209.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","3209.44","52","","","Percent of Total Billed Charges","neg_dollar:$3209.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","5307.92","86","","","Percent of Total Billed Charges","neg_dollar:$5307.92","4320.40","70","","","Percent of Total Billed Charges","neg_dollar:$4320.40","3209.44","52","","","Percent of Total Billed Charges","neg_dollar:$3209.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","3626.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$3626.04;102% of Medicaid interim rate","4629.00","75","","","Percent of Total Billed Charges","neg_dollar:$4629","5307.92","86","","","Percent of Total Billed Charges","neg_dollar:$5307.92","4320.40","70","","","Percent of Total Billed Charges","neg_dollar:$4320.40","3518.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$3518.03;103.5% of Medicaid interim rate","6172.00","150","","","Percent of Total Billed Charges","neg_dollar:$9542.22;150% of Medicaid interim rate","4937.60","80","","","Percent of Total Billed Charges","neg_dollar:$4937.60;Percent of Total Billed Charges","","","","5150.00","Fee Schedule","","3209.44","52","","","Percent of Total Billed Charges","neg_dollar:$3209.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","3209.44","52","","","Percent of Total Billed Charges","neg_dollar:$3209.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","6172.00",""
"X-RAY EXAM CHEST 1 VIEW","71045","CPT","70000800","CDM","324","RC","","Facility","Outpatient","","","324","259.20","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","190.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$190.34;102% of Medicaid interim rate","243.00","75","","","Percent of Total Billed Charges","neg_dollar:$243","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","184.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$184.67;103.5% of Medicaid interim rate","324.00","150","","","Percent of Total Billed Charges","neg_dollar:$500.92;150% of Medicaid interim rate","259.20","80","","","Percent of Total Billed Charges","neg_dollar:$259.20;Percent of Total Billed Charges","","","","162.00","Fee Schedule","","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.00","324.00",""
"X-RAY EXAM CHEST 2 VIEWS","71046","CPT","70000801","CDM","324","RC","","Facility","Outpatient","","","357","285.60","357.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","185.64","52","","","Percent of Total Billed Charges","neg_dollar:$185.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","357.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","185.64","52","","","Percent of Total Billed Charges","neg_dollar:$185.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","185.64","52","","","Percent of Total Billed Charges","neg_dollar:$185.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","185.64","52","","","Percent of Total Billed Charges","neg_dollar:$185.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","307.02","86","","","Percent of Total Billed Charges","neg_dollar:$307.02","249.89","70","","","Percent of Total Billed Charges","neg_dollar:$249.89","185.64","52","","","Percent of Total Billed Charges","neg_dollar:$185.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","209.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$209.73;102% of Medicaid interim rate","267.75","75","","","Percent of Total Billed Charges","neg_dollar:$267.75","307.02","86","","","Percent of Total Billed Charges","neg_dollar:$307.02","249.89","70","","","Percent of Total Billed Charges","neg_dollar:$249.89","203.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$203.48;103.5% of Medicaid interim rate","357.00","150","","","Percent of Total Billed Charges","neg_dollar:$551.93;150% of Medicaid interim rate","285.60","80","","","Percent of Total Billed Charges","neg_dollar:$285.60;Percent of Total Billed Charges","","","","282.00","Fee Schedule","","185.64","52","","","Percent of Total Billed Charges","neg_dollar:$185.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","185.64","52","","","Percent of Total Billed Charges","neg_dollar:$185.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","185.00","357.00",""
"X-RAY EXAM CHEST 3 VIEWS","71047","CPT","70000802","CDM","324","RC","","Facility","Outpatient","","","366","292.80","366.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","190.32","52","","","Percent of Total Billed Charges","neg_dollar:$190.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","366.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","190.32","52","","","Percent of Total Billed Charges","neg_dollar:$190.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","190.32","52","","","Percent of Total Billed Charges","neg_dollar:$190.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","190.32","52","","","Percent of Total Billed Charges","neg_dollar:$190.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","314.76","86","","","Percent of Total Billed Charges","neg_dollar:$314.76","256.20","70","","","Percent of Total Billed Charges","neg_dollar:$256.20","190.32","52","","","Percent of Total Billed Charges","neg_dollar:$190.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","215.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$215.02;102% of Medicaid interim rate","274.50","75","","","Percent of Total Billed Charges","neg_dollar:$274.50","314.76","86","","","Percent of Total Billed Charges","neg_dollar:$314.76","256.20","70","","","Percent of Total Billed Charges","neg_dollar:$256.20","208.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$208.61;103.5% of Medicaid interim rate","366.00","150","","","Percent of Total Billed Charges","neg_dollar:$565.85;150% of Medicaid interim rate","292.80","80","","","Percent of Total Billed Charges","neg_dollar:$292.80;Percent of Total Billed Charges","","","","366.00","Fee Schedule","","190.32","52","","","Percent of Total Billed Charges","neg_dollar:$190.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","190.32","52","","","Percent of Total Billed Charges","neg_dollar:$190.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","190.00","366.00",""
"X-RAY EXAM CHEST 4+ VIEWS","71048","CPT","70000803","CDM","324","RC","","Facility","Outpatient","","","580","464.00","580.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","580.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","498.80","86","","","Percent of Total Billed Charges","neg_dollar:$498.80","406.00","70","","","Percent of Total Billed Charges","neg_dollar:$406","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","340.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$340.74;102% of Medicaid interim rate","435.00","75","","","Percent of Total Billed Charges","neg_dollar:$435","498.80","86","","","Percent of Total Billed Charges","neg_dollar:$498.80","406.00","70","","","Percent of Total Billed Charges","neg_dollar:$406","330.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$330.59;103.5% of Medicaid interim rate","580.00","150","","","Percent of Total Billed Charges","neg_dollar:$896.70;150% of Medicaid interim rate","464.00","80","","","Percent of Total Billed Charges","neg_dollar:$464;Percent of Total Billed Charges","","","","580.00","Fee Schedule","","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","301.60","52","","","Percent of Total Billed Charges","neg_dollar:$301.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","301.00","580.00",""
"RIBS UNILATERAL 2 VIEWS","71100","CPT","70000049","CDM","320","RC","","Facility","Outpatient","","","358","286.40","358.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","358.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","307.88","86","","","Percent of Total Billed Charges","neg_dollar:$307.88","250.60","70","","","Percent of Total Billed Charges","neg_dollar:$250.60","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","210.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$210.32;102% of Medicaid interim rate","268.50","75","","","Percent of Total Billed Charges","neg_dollar:$268.50","307.88","86","","","Percent of Total Billed Charges","neg_dollar:$307.88","250.60","70","","","Percent of Total Billed Charges","neg_dollar:$250.60","204.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$204.05;103.5% of Medicaid interim rate","358.00","150","","","Percent of Total Billed Charges","neg_dollar:$553.48;150% of Medicaid interim rate","286.40","80","","","Percent of Total Billed Charges","neg_dollar:$286.40;Percent of Total Billed Charges","","","","358.00","Fee Schedule","","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","186.00","358.00",""
"RIBS CHEST UNIL MIN 3 VIEWS","71101","CPT","70000050","CDM","320","RC","","Facility","Outpatient","","","448","358.40","448.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","448.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","385.28","86","","","Percent of Total Billed Charges","neg_dollar:$385.28","313.59","70","","","Percent of Total Billed Charges","neg_dollar:$313.59","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","263.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$263.19;102% of Medicaid interim rate","336.00","75","","","Percent of Total Billed Charges","neg_dollar:$336","385.28","86","","","Percent of Total Billed Charges","neg_dollar:$385.28","313.59","70","","","Percent of Total Billed Charges","neg_dollar:$313.59","255.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$255.35;103.5% of Medicaid interim rate","448.00","150","","","Percent of Total Billed Charges","neg_dollar:$692.63;150% of Medicaid interim rate","358.40","80","","","Percent of Total Billed Charges","neg_dollar:$358.40;Percent of Total Billed Charges","","","","448.00","Fee Schedule","","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","232.00","448.00",""
"RIBS BILAT 3 VIEWS","71110","CPT","70000051","CDM","320","RC","","Facility","Outpatient","","","462","369.60","462.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","240.24","52","","","Percent of Total Billed Charges","neg_dollar:$240.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","462.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","240.24","52","","","Percent of Total Billed Charges","neg_dollar:$240.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","240.24","52","","","Percent of Total Billed Charges","neg_dollar:$240.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","240.24","52","","","Percent of Total Billed Charges","neg_dollar:$240.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","397.32","86","","","Percent of Total Billed Charges","neg_dollar:$397.32","323.40","70","","","Percent of Total Billed Charges","neg_dollar:$323.40","240.24","52","","","Percent of Total Billed Charges","neg_dollar:$240.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","271.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$271.42;102% of Medicaid interim rate","346.50","75","","","Percent of Total Billed Charges","neg_dollar:$346.50","397.32","86","","","Percent of Total Billed Charges","neg_dollar:$397.32","323.40","70","","","Percent of Total Billed Charges","neg_dollar:$323.40","263.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$263.34;103.5% of Medicaid interim rate","462.00","150","","","Percent of Total Billed Charges","neg_dollar:$714.27;150% of Medicaid interim rate","369.60","80","","","Percent of Total Billed Charges","neg_dollar:$369.60;Percent of Total Billed Charges","","","","317.00","Fee Schedule","","240.24","52","","","Percent of Total Billed Charges","neg_dollar:$240.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","240.24","52","","","Percent of Total Billed Charges","neg_dollar:$240.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","240.00","462.00",""
"RIBS CHEST BILAT MIN 4 VIEWS","71111","CPT","70000052","CDM","320","RC","","Facility","Outpatient","","","521","416.80","521.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","521.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","448.06","86","","","Percent of Total Billed Charges","neg_dollar:$448.06","364.70","70","","","Percent of Total Billed Charges","neg_dollar:$364.70","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","306.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$306.08;102% of Medicaid interim rate","390.75","75","","","Percent of Total Billed Charges","neg_dollar:$390.75","448.06","86","","","Percent of Total Billed Charges","neg_dollar:$448.06","364.70","70","","","Percent of Total Billed Charges","neg_dollar:$364.70","296.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$296.96;103.5% of Medicaid interim rate","521.00","150","","","Percent of Total Billed Charges","neg_dollar:$805.49;150% of Medicaid interim rate","416.80","80","","","Percent of Total Billed Charges","neg_dollar:$416.80;Percent of Total Billed Charges","","","","348.00","Fee Schedule","","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","270.00","521.00",""
"STERNUM MIN 2 VIEWS","71120","CPT","70000053","CDM","320","RC","","Facility","Outpatient","","","300","240.00","300.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;101% Medicare Outpatient Cost to Charge Ratio of 52%","300.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;102% Medicare Outpatient Cost to Charge Ratio of 52%","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;102% Medicare Outpatient Cost to Charge Ratio of 52%","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;102% Medicare Outpatient Cost to Charge Ratio of 52%","258.00","86","","","Percent of Total Billed Charges","neg_dollar:$258","210.00","70","","","Percent of Total Billed Charges","neg_dollar:$210","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;105% Medicare Outpatient Cost to Charge Ratio of 52%","176.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$176.24;102% of Medicaid interim rate","225.00","75","","","Percent of Total Billed Charges","neg_dollar:$225","258.00","86","","","Percent of Total Billed Charges","neg_dollar:$258","210.00","70","","","Percent of Total Billed Charges","neg_dollar:$210","170.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$170.99;103.5% of Medicaid interim rate","300.00","150","","","Percent of Total Billed Charges","neg_dollar:$463.81;150% of Medicaid interim rate","240.00","80","","","Percent of Total Billed Charges","neg_dollar:$240;Percent of Total Billed Charges","","","","300.00","Fee Schedule","","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;100% Medicare Outpatient Cost to Charge Ratio of 52%","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;100% Medicare Outpatient Cost to Charge Ratio of 52%","156.00","300.00",""
"STERNOCLAVICULAR MIN 3 VIEWS","71130","CPT","70000320","CDM","320","RC","","Facility","Outpatient","","","328","262.40","328.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","170.56","52","","","Percent of Total Billed Charges","neg_dollar:$170.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","328.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","170.56","52","","","Percent of Total Billed Charges","neg_dollar:$170.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","170.56","52","","","Percent of Total Billed Charges","neg_dollar:$170.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","170.56","52","","","Percent of Total Billed Charges","neg_dollar:$170.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","282.08","86","","","Percent of Total Billed Charges","neg_dollar:$282.08","229.60","70","","","Percent of Total Billed Charges","neg_dollar:$229.60","170.56","52","","","Percent of Total Billed Charges","neg_dollar:$170.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","192.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$192.69;102% of Medicaid interim rate","246.00","75","","","Percent of Total Billed Charges","neg_dollar:$246","282.08","86","","","Percent of Total Billed Charges","neg_dollar:$282.08","229.60","70","","","Percent of Total Billed Charges","neg_dollar:$229.60","186.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$186.95;103.5% of Medicaid interim rate","328.00","150","","","Percent of Total Billed Charges","neg_dollar:$507.10;150% of Medicaid interim rate","262.40","80","","","Percent of Total Billed Charges","neg_dollar:$262.40;Percent of Total Billed Charges","","","","328.00","Fee Schedule","","170.56","52","","","Percent of Total Billed Charges","neg_dollar:$170.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","170.56","52","","","Percent of Total Billed Charges","neg_dollar:$170.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","170.00","328.00",""
"CT CHEST WO CONTRAST DIAG","71250","CPT","70000054","CDM","352","RC","","Facility","Outpatient","","","2185","1748.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1136.20","52","","","Percent of Total Billed Charges","neg_dollar:$1136.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1136.20","52","","","Percent of Total Billed Charges","neg_dollar:$1136.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","1136.20","52","","","Percent of Total Billed Charges","neg_dollar:$1136.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","1136.20","52","","","Percent of Total Billed Charges","neg_dollar:$1136.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","1879.10","86","","","Percent of Total Billed Charges","neg_dollar:$1879.10","1529.50","70","","","Percent of Total Billed Charges","neg_dollar:$1529.50","1136.20","52","","","Percent of Total Billed Charges","neg_dollar:$1136.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","1283.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$1283.68;102% of Medicaid interim rate","1638.75","75","","","Percent of Total Billed Charges","neg_dollar:$1638.75","1879.10","86","","","Percent of Total Billed Charges","neg_dollar:$1879.10","1529.50","70","","","Percent of Total Billed Charges","neg_dollar:$1529.50","1245.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$1245.44;103.5% of Medicaid interim rate","2185.00","150","","","Percent of Total Billed Charges","neg_dollar:$3378.11;150% of Medicaid interim rate","1748.00","80","","","Percent of Total Billed Charges","neg_dollar:$1748;Percent of Total Billed Charges","","","","1090.00","Fee Schedule","","1136.20","52","","","Percent of Total Billed Charges","neg_dollar:$1136.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","1136.20","52","","","Percent of Total Billed Charges","neg_dollar:$1136.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2185.00",""
"CT CHEST W CONTRAST DIAG","71260","CPT","70000055","CDM","352","RC","","Facility","Outpatient","","","2648","2118.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1376.96","52","","","Percent of Total Billed Charges","neg_dollar:$1376.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1376.96","52","","","Percent of Total Billed Charges","neg_dollar:$1376.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1376.96","52","","","Percent of Total Billed Charges","neg_dollar:$1376.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1376.96","52","","","Percent of Total Billed Charges","neg_dollar:$1376.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","2277.27","86","","","Percent of Total Billed Charges","neg_dollar:$2277.27","1853.60","70","","","Percent of Total Billed Charges","neg_dollar:$1853.60","1376.96","52","","","Percent of Total Billed Charges","neg_dollar:$1376.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","1555.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$1555.69;102% of Medicaid interim rate","1986.00","75","","","Percent of Total Billed Charges","neg_dollar:$1986","2277.27","86","","","Percent of Total Billed Charges","neg_dollar:$2277.27","1853.60","70","","","Percent of Total Billed Charges","neg_dollar:$1853.60","1509.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$1509.36;103.5% of Medicaid interim rate","2648.00","150","","","Percent of Total Billed Charges","neg_dollar:$4093.94;150% of Medicaid interim rate","2118.40","80","","","Percent of Total Billed Charges","neg_dollar:$2118.40;Percent of Total Billed Charges","","","","1712.00","Fee Schedule","","1376.96","52","","","Percent of Total Billed Charges","neg_dollar:$1376.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","1376.96","52","","","Percent of Total Billed Charges","neg_dollar:$1376.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2648.00",""
"CT CHEST W WO CONTRAST DIAG","71270","CPT","70000056","CDM","352","RC","","Facility","Outpatient","","","3111","2488.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1617.72","52","","","Percent of Total Billed Charges","neg_dollar:$1617.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1617.72","52","","","Percent of Total Billed Charges","neg_dollar:$1617.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1617.72","52","","","Percent of Total Billed Charges","neg_dollar:$1617.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1617.72","52","","","Percent of Total Billed Charges","neg_dollar:$1617.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","2675.46","86","","","Percent of Total Billed Charges","neg_dollar:$2675.46","2177.70","70","","","Percent of Total Billed Charges","neg_dollar:$2177.70","1617.72","52","","","Percent of Total Billed Charges","neg_dollar:$1617.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","1827.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$1827.70;102% of Medicaid interim rate","2333.25","75","","","Percent of Total Billed Charges","neg_dollar:$2333.25","2675.46","86","","","Percent of Total Billed Charges","neg_dollar:$2675.46","2177.70","70","","","Percent of Total Billed Charges","neg_dollar:$2177.70","1773.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$1773.26;103.5% of Medicaid interim rate","3111.00","150","","","Percent of Total Billed Charges","neg_dollar:$4809.76;150% of Medicaid interim rate","2488.80","80","","","Percent of Total Billed Charges","neg_dollar:$2488.80;Percent of Total Billed Charges","","","","2187.00","Fee Schedule","","1617.72","52","","","Percent of Total Billed Charges","neg_dollar:$1617.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1617.72","52","","","Percent of Total Billed Charges","neg_dollar:$1617.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3111.00",""
"CT THORAX LUNG CANCER SCREEN","71271","CPT","70000863","CDM","352","RC","","Facility","Outpatient","","","637","509.60","637.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","331.24","52","","","Percent of Total Billed Charges","neg_dollar:$331.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","637.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","331.24","52","","","Percent of Total Billed Charges","neg_dollar:$331.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","331.24","52","","","Percent of Total Billed Charges","neg_dollar:$331.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","331.24","52","","","Percent of Total Billed Charges","neg_dollar:$331.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","547.81","86","","","Percent of Total Billed Charges","neg_dollar:$547.81","445.90","70","","","Percent of Total Billed Charges","neg_dollar:$445.90","331.24","52","","","Percent of Total Billed Charges","neg_dollar:$331.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","374.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$374.23;102% of Medicaid interim rate","477.75","75","","","Percent of Total Billed Charges","neg_dollar:$477.75","547.81","86","","","Percent of Total Billed Charges","neg_dollar:$547.81","445.90","70","","","Percent of Total Billed Charges","neg_dollar:$445.90","363.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$363.09;103.5% of Medicaid interim rate","637.00","150","","","Percent of Total Billed Charges","neg_dollar:$984.83;150% of Medicaid interim rate","509.60","80","","","Percent of Total Billed Charges","neg_dollar:$509.60;Percent of Total Billed Charges","","","","412.00","Fee Schedule","","331.24","52","","","Percent of Total Billed Charges","neg_dollar:$331.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","331.24","52","","","Percent of Total Billed Charges","neg_dollar:$331.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","331.00","637.00",""
"CT ANGIOGRAPHY CHEST W WO CONTRAST","71275","CPT","70000057","CDM","352","RC","","Facility","Outpatient","","","2955","2364.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1536.60","52","","","Percent of Total Billed Charges","neg_dollar:$1536.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1536.60","52","","","Percent of Total Billed Charges","neg_dollar:$1536.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","1536.60","52","","","Percent of Total Billed Charges","neg_dollar:$1536.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","1536.60","52","","","Percent of Total Billed Charges","neg_dollar:$1536.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","2541.30","86","","","Percent of Total Billed Charges","neg_dollar:$2541.30","2068.50","70","","","Percent of Total Billed Charges","neg_dollar:$2068.50","1536.60","52","","","Percent of Total Billed Charges","neg_dollar:$1536.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","1736.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1736.05;102% of Medicaid interim rate","2216.25","75","","","Percent of Total Billed Charges","neg_dollar:$2216.25","2541.30","86","","","Percent of Total Billed Charges","neg_dollar:$2541.30","2068.50","70","","","Percent of Total Billed Charges","neg_dollar:$2068.50","1684.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$1684.35;103.5% of Medicaid interim rate","2955.00","150","","","Percent of Total Billed Charges","neg_dollar:$4568.57;150% of Medicaid interim rate","2364.00","80","","","Percent of Total Billed Charges","neg_dollar:$2364;Percent of Total Billed Charges","","","","1474.00","Fee Schedule","","1536.60","52","","","Percent of Total Billed Charges","neg_dollar:$1536.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1536.60","52","","","Percent of Total Billed Charges","neg_dollar:$1536.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2955.00",""
"MRI CHEST WO CONTRAST","71550","CPT","70000058","CDM","610","RC","","Facility","Outpatient","","","3563","2850.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1852.76","52","","","Percent of Total Billed Charges","neg_dollar:$1852.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1852.76","52","","","Percent of Total Billed Charges","neg_dollar:$1852.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1852.76","52","","","Percent of Total Billed Charges","neg_dollar:$1852.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1852.76","52","","","Percent of Total Billed Charges","neg_dollar:$1852.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","3064.18","86","","","Percent of Total Billed Charges","neg_dollar:$3064.18","2494.10","70","","","Percent of Total Billed Charges","neg_dollar:$2494.10","1852.76","52","","","Percent of Total Billed Charges","neg_dollar:$1852.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","2093.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$2093.25;102% of Medicaid interim rate","2672.25","75","","","Percent of Total Billed Charges","neg_dollar:$2672.25","3064.18","86","","","Percent of Total Billed Charges","neg_dollar:$3064.18","2494.10","70","","","Percent of Total Billed Charges","neg_dollar:$2494.10","2030.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$2030.90;103.5% of Medicaid interim rate","3563.00","150","","","Percent of Total Billed Charges","neg_dollar:$5508.57;150% of Medicaid interim rate","2850.40","80","","","Percent of Total Billed Charges","neg_dollar:$2850.40;Percent of Total Billed Charges","","","","3563.00","Fee Schedule","","1852.76","52","","","Percent of Total Billed Charges","neg_dollar:$1852.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1852.76","52","","","Percent of Total Billed Charges","neg_dollar:$1852.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3563.00",""
"MRI CHEST W CONTRAST","71551","CPT","70000059","CDM","610","RC","","Facility","Outpatient","","","4026","3220.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2093.52","52","","","Percent of Total Billed Charges","neg_dollar:$2093.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2093.52","52","","","Percent of Total Billed Charges","neg_dollar:$2093.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","2093.52","52","","","Percent of Total Billed Charges","neg_dollar:$2093.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","2093.52","52","","","Percent of Total Billed Charges","neg_dollar:$2093.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","3462.36","86","","","Percent of Total Billed Charges","neg_dollar:$3462.36","2818.20","70","","","Percent of Total Billed Charges","neg_dollar:$2818.20","2093.52","52","","","Percent of Total Billed Charges","neg_dollar:$2093.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","2365.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$2365.27;102% of Medicaid interim rate","3019.50","75","","","Percent of Total Billed Charges","neg_dollar:$3019.50","3462.36","86","","","Percent of Total Billed Charges","neg_dollar:$3462.36","2818.20","70","","","Percent of Total Billed Charges","neg_dollar:$2818.20","2294.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$2294.81;103.5% of Medicaid interim rate","4026.00","150","","","Percent of Total Billed Charges","neg_dollar:$6224.39;150% of Medicaid interim rate","3220.80","80","","","Percent of Total Billed Charges","neg_dollar:$3220.80;Percent of Total Billed Charges","","","","4026.00","Fee Schedule","","2093.52","52","","","Percent of Total Billed Charges","neg_dollar:$2093.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","2093.52","52","","","Percent of Total Billed Charges","neg_dollar:$2093.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4026.00",""
"MRI CHEST W WO CONTRAST","71552","CPT","70000060","CDM","610","RC","","Facility","Outpatient","","","5255","4204.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2732.60","52","","","Percent of Total Billed Charges","neg_dollar:$2732.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2732.60","52","","","Percent of Total Billed Charges","neg_dollar:$2732.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","2732.60","52","","","Percent of Total Billed Charges","neg_dollar:$2732.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","2732.60","52","","","Percent of Total Billed Charges","neg_dollar:$2732.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","4519.30","86","","","Percent of Total Billed Charges","neg_dollar:$4519.30","3678.49","70","","","Percent of Total Billed Charges","neg_dollar:$3678.49","2732.60","52","","","Percent of Total Billed Charges","neg_dollar:$2732.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","3087.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$3087.30;102% of Medicaid interim rate","3941.25","75","","","Percent of Total Billed Charges","neg_dollar:$3941.25","4519.30","86","","","Percent of Total Billed Charges","neg_dollar:$4519.30","3678.49","70","","","Percent of Total Billed Charges","neg_dollar:$3678.49","2995.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$2995.35;103.5% of Medicaid interim rate","5255.00","150","","","Percent of Total Billed Charges","neg_dollar:$8124.49;150% of Medicaid interim rate","4204.00","80","","","Percent of Total Billed Charges","neg_dollar:$4204;Percent of Total Billed Charges","","","","5255.00","Fee Schedule","","2732.60","52","","","Percent of Total Billed Charges","neg_dollar:$2732.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","2732.60","52","","","Percent of Total Billed Charges","neg_dollar:$2732.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5255.00",""
"MRA CHEST W WO CONTRAST","71555","CPT","70000307","CDM","610","RC","","Facility","Outpatient","","","5600","4480.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2912.00","52","","","Percent of Total Billed Charges","neg_dollar:$2912;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2912.00","52","","","Percent of Total Billed Charges","neg_dollar:$2912;102% Medicare Outpatient Cost to Charge Ratio of 52%","2912.00","52","","","Percent of Total Billed Charges","neg_dollar:$2912;102% Medicare Outpatient Cost to Charge Ratio of 52%","2912.00","52","","","Percent of Total Billed Charges","neg_dollar:$2912;102% Medicare Outpatient Cost to Charge Ratio of 52%","4816.00","86","","","Percent of Total Billed Charges","neg_dollar:$4816","3919.99","70","","","Percent of Total Billed Charges","neg_dollar:$3919.99","2912.00","52","","","Percent of Total Billed Charges","neg_dollar:$2912;105% Medicare Outpatient Cost to Charge Ratio of 52%","3289.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$3289.99;102% of Medicaid interim rate","4200.00","75","","","Percent of Total Billed Charges","neg_dollar:$4200","4816.00","86","","","Percent of Total Billed Charges","neg_dollar:$4816","3919.99","70","","","Percent of Total Billed Charges","neg_dollar:$3919.99","3191.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$3191.99;103.5% of Medicaid interim rate","5600.00","150","","","Percent of Total Billed Charges","neg_dollar:$8657.88;150% of Medicaid interim rate","4480.00","80","","","Percent of Total Billed Charges","neg_dollar:$4480;Percent of Total Billed Charges","","","","5600.00","Fee Schedule","","2912.00","52","","","Percent of Total Billed Charges","neg_dollar:$2912;100% Medicare Outpatient Cost to Charge Ratio of 52%","2912.00","52","","","Percent of Total Billed Charges","neg_dollar:$2912;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5600.00",""
"SPINE 1 VIEW ANY LOCATION","72020","CPT","70000061","CDM","320","RC","","Facility","Outpatient","","","285","228.00","285.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","285.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","245.10","86","","","Percent of Total Billed Charges","neg_dollar:$245.10","199.50","70","","","Percent of Total Billed Charges","neg_dollar:$199.50","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","167.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$167.43;102% of Medicaid interim rate","213.75","75","","","Percent of Total Billed Charges","neg_dollar:$213.75","245.10","86","","","Percent of Total Billed Charges","neg_dollar:$245.10","199.50","70","","","Percent of Total Billed Charges","neg_dollar:$199.50","162.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$162.45;103.5% of Medicaid interim rate","285.00","150","","","Percent of Total Billed Charges","neg_dollar:$440.62;150% of Medicaid interim rate","228.00","80","","","Percent of Total Billed Charges","neg_dollar:$228;Percent of Total Billed Charges","","","","285.00","Fee Schedule","","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","148.00","285.00",""
"CERVICAL SPINE 2 OR 3 VIEWS","72040","CPT","70000062","CDM","320","RC","","Facility","Outpatient","","","369","295.20","369.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","191.88","52","","","Percent of Total Billed Charges","neg_dollar:$191.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","369.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","191.88","52","","","Percent of Total Billed Charges","neg_dollar:$191.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","191.88","52","","","Percent of Total Billed Charges","neg_dollar:$191.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","191.88","52","","","Percent of Total Billed Charges","neg_dollar:$191.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","317.34","86","","","Percent of Total Billed Charges","neg_dollar:$317.34","258.30","70","","","Percent of Total Billed Charges","neg_dollar:$258.30","191.88","52","","","Percent of Total Billed Charges","neg_dollar:$191.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","216.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$216.78;102% of Medicaid interim rate","276.75","75","","","Percent of Total Billed Charges","neg_dollar:$276.75","317.34","86","","","Percent of Total Billed Charges","neg_dollar:$317.34","258.30","70","","","Percent of Total Billed Charges","neg_dollar:$258.30","210.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$210.32;103.5% of Medicaid interim rate","369.00","150","","","Percent of Total Billed Charges","neg_dollar:$570.49;150% of Medicaid interim rate","295.20","80","","","Percent of Total Billed Charges","neg_dollar:$295.20;Percent of Total Billed Charges","","","","300.00","Fee Schedule","","191.88","52","","","Percent of Total Billed Charges","neg_dollar:$191.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","191.88","52","","","Percent of Total Billed Charges","neg_dollar:$191.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","191.00","369.00",""
"CERVICAL SPINE MIN 4 VIEWS","72050","CPT","70000063","CDM","320","RC","","Facility","Outpatient","","","431","344.80","431.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","431.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","370.65","86","","","Percent of Total Billed Charges","neg_dollar:$370.65","301.70","70","","","Percent of Total Billed Charges","neg_dollar:$301.70","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","253.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$253.21;102% of Medicaid interim rate","323.25","75","","","Percent of Total Billed Charges","neg_dollar:$323.25","370.65","86","","","Percent of Total Billed Charges","neg_dollar:$370.65","301.70","70","","","Percent of Total Billed Charges","neg_dollar:$301.70","245.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$245.67;103.5% of Medicaid interim rate","431.00","150","","","Percent of Total Billed Charges","neg_dollar:$666.34;150% of Medicaid interim rate","344.80","80","","","Percent of Total Billed Charges","neg_dollar:$344.80;Percent of Total Billed Charges","","","","302.00","Fee Schedule","","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","224.00","431.00",""
"COMPLETE CERVICAL SPINE","72052","CPT","70000064","CDM","320","RC","","Facility","Outpatient","","","536","428.80","536.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","278.72","52","","","Percent of Total Billed Charges","neg_dollar:$278.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","536.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","278.72","52","","","Percent of Total Billed Charges","neg_dollar:$278.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","278.72","52","","","Percent of Total Billed Charges","neg_dollar:$278.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","278.72","52","","","Percent of Total Billed Charges","neg_dollar:$278.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","460.96","86","","","Percent of Total Billed Charges","neg_dollar:$460.96","375.20","70","","","Percent of Total Billed Charges","neg_dollar:$375.20","278.72","52","","","Percent of Total Billed Charges","neg_dollar:$278.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","314.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$314.89;102% of Medicaid interim rate","402.00","75","","","Percent of Total Billed Charges","neg_dollar:$402","460.96","86","","","Percent of Total Billed Charges","neg_dollar:$460.96","375.20","70","","","Percent of Total Billed Charges","neg_dollar:$375.20","305.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$305.52;103.5% of Medicaid interim rate","536.00","150","","","Percent of Total Billed Charges","neg_dollar:$828.68;150% of Medicaid interim rate","428.80","80","","","Percent of Total Billed Charges","neg_dollar:$428.80;Percent of Total Billed Charges","","","","536.00","Fee Schedule","","278.72","52","","","Percent of Total Billed Charges","neg_dollar:$278.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","278.72","52","","","Percent of Total Billed Charges","neg_dollar:$278.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","278.00","536.00",""
"THORACIC SPINE 2 VIEWS","72070","CPT","70000066","CDM","320","RC","","Facility","Outpatient","","","380","304.00","380.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","197.60","52","","","Percent of Total Billed Charges","neg_dollar:$197.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","380.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","197.60","52","","","Percent of Total Billed Charges","neg_dollar:$197.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","197.60","52","","","Percent of Total Billed Charges","neg_dollar:$197.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","197.60","52","","","Percent of Total Billed Charges","neg_dollar:$197.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","326.80","86","","","Percent of Total Billed Charges","neg_dollar:$326.80","266.00","70","","","Percent of Total Billed Charges","neg_dollar:$266","197.60","52","","","Percent of Total Billed Charges","neg_dollar:$197.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","223.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$223.24;102% of Medicaid interim rate","285.00","75","","","Percent of Total Billed Charges","neg_dollar:$285","326.80","86","","","Percent of Total Billed Charges","neg_dollar:$326.80","266.00","70","","","Percent of Total Billed Charges","neg_dollar:$266","216.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$216.60;103.5% of Medicaid interim rate","380.00","150","","","Percent of Total Billed Charges","neg_dollar:$587.49;150% of Medicaid interim rate","304.00","80","","","Percent of Total Billed Charges","neg_dollar:$304;Percent of Total Billed Charges","","","","260.00","Fee Schedule","","197.60","52","","","Percent of Total Billed Charges","neg_dollar:$197.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","197.60","52","","","Percent of Total Billed Charges","neg_dollar:$197.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","197.00","380.00",""
"THORACIC SPINE 3 VIEWS","72072","CPT","70000321","CDM","320","RC","","Facility","Outpatient","","","400","320.00","400.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","208.00","52","","","Percent of Total Billed Charges","neg_dollar:$208;101% Medicare Outpatient Cost to Charge Ratio of 52%","400.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","208.00","52","","","Percent of Total Billed Charges","neg_dollar:$208;102% Medicare Outpatient Cost to Charge Ratio of 52%","208.00","52","","","Percent of Total Billed Charges","neg_dollar:$208;102% Medicare Outpatient Cost to Charge Ratio of 52%","208.00","52","","","Percent of Total Billed Charges","neg_dollar:$208;102% Medicare Outpatient Cost to Charge Ratio of 52%","344.00","86","","","Percent of Total Billed Charges","neg_dollar:$344","280.00","70","","","Percent of Total Billed Charges","neg_dollar:$280","208.00","52","","","Percent of Total Billed Charges","neg_dollar:$208;105% Medicare Outpatient Cost to Charge Ratio of 52%","234.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$234.99;102% of Medicaid interim rate","300.00","75","","","Percent of Total Billed Charges","neg_dollar:$300","344.00","86","","","Percent of Total Billed Charges","neg_dollar:$344","280.00","70","","","Percent of Total Billed Charges","neg_dollar:$280","227.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$227.99;103.5% of Medicaid interim rate","400.00","150","","","Percent of Total Billed Charges","neg_dollar:$618.42;150% of Medicaid interim rate","320.00","80","","","Percent of Total Billed Charges","neg_dollar:$320;Percent of Total Billed Charges","","","","325.00","Fee Schedule","","208.00","52","","","Percent of Total Billed Charges","neg_dollar:$208;100% Medicare Outpatient Cost to Charge Ratio of 52%","208.00","52","","","Percent of Total Billed Charges","neg_dollar:$208;100% Medicare Outpatient Cost to Charge Ratio of 52%","208.00","400.00",""
"THORACIC SPINE MIN 4 VIEWS","72074","CPT","70000067","CDM","320","RC","","Facility","Outpatient","","","433","346.40","433.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","225.16","52","","","Percent of Total Billed Charges","neg_dollar:$225.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","433.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","225.16","52","","","Percent of Total Billed Charges","neg_dollar:$225.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","225.16","52","","","Percent of Total Billed Charges","neg_dollar:$225.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","225.16","52","","","Percent of Total Billed Charges","neg_dollar:$225.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","372.38","86","","","Percent of Total Billed Charges","neg_dollar:$372.38","303.09","70","","","Percent of Total Billed Charges","neg_dollar:$303.09","225.16","52","","","Percent of Total Billed Charges","neg_dollar:$225.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","254.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$254.38;102% of Medicaid interim rate","324.75","75","","","Percent of Total Billed Charges","neg_dollar:$324.75","372.38","86","","","Percent of Total Billed Charges","neg_dollar:$372.38","303.09","70","","","Percent of Total Billed Charges","neg_dollar:$303.09","246.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$246.80;103.5% of Medicaid interim rate","433.00","150","","","Percent of Total Billed Charges","neg_dollar:$669.43;150% of Medicaid interim rate","346.40","80","","","Percent of Total Billed Charges","neg_dollar:$346.40;Percent of Total Billed Charges","","","","433.00","Fee Schedule","","225.16","52","","","Percent of Total Billed Charges","neg_dollar:$225.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","225.16","52","","","Percent of Total Billed Charges","neg_dollar:$225.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","225.00","433.00",""
"X-RAY EXAM ENTIRE SPINE 2/3 VW","72082","CPT","70000751","CDM","320","RC","","Facility","Outpatient","","","389","311.20","389.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","202.28","52","","","Percent of Total Billed Charges","neg_dollar:$202.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","389.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","202.28","52","","","Percent of Total Billed Charges","neg_dollar:$202.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","202.28","52","","","Percent of Total Billed Charges","neg_dollar:$202.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","202.28","52","","","Percent of Total Billed Charges","neg_dollar:$202.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","334.54","86","","","Percent of Total Billed Charges","neg_dollar:$334.54","272.29","70","","","Percent of Total Billed Charges","neg_dollar:$272.29","202.28","52","","","Percent of Total Billed Charges","neg_dollar:$202.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","228.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$228.53;102% of Medicaid interim rate","291.75","75","","","Percent of Total Billed Charges","neg_dollar:$291.75","334.54","86","","","Percent of Total Billed Charges","neg_dollar:$334.54","272.29","70","","","Percent of Total Billed Charges","neg_dollar:$272.29","221.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$221.73;103.5% of Medicaid interim rate","389.00","150","","","Percent of Total Billed Charges","neg_dollar:$601.41;150% of Medicaid interim rate","311.20","80","","","Percent of Total Billed Charges","neg_dollar:$311.20;Percent of Total Billed Charges","","","","389.00","Fee Schedule","","202.28","52","","","Percent of Total Billed Charges","neg_dollar:$202.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","202.28","52","","","Percent of Total Billed Charges","neg_dollar:$202.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","202.00","389.00",""
"LUMBOSACR SPINE 2 OR 3 VIEWS","72100","CPT","70000068","CDM","320","RC","","Facility","Outpatient","","","377","301.60","377.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","196.04","52","","","Percent of Total Billed Charges","neg_dollar:$196.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","377.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","196.04","52","","","Percent of Total Billed Charges","neg_dollar:$196.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","196.04","52","","","Percent of Total Billed Charges","neg_dollar:$196.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","196.04","52","","","Percent of Total Billed Charges","neg_dollar:$196.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","324.21","86","","","Percent of Total Billed Charges","neg_dollar:$324.21","263.90","70","","","Percent of Total Billed Charges","neg_dollar:$263.90","196.04","52","","","Percent of Total Billed Charges","neg_dollar:$196.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","221.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$221.48;102% of Medicaid interim rate","282.75","75","","","Percent of Total Billed Charges","neg_dollar:$282.75","324.21","86","","","Percent of Total Billed Charges","neg_dollar:$324.21","263.90","70","","","Percent of Total Billed Charges","neg_dollar:$263.90","214.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$214.89;103.5% of Medicaid interim rate","377.00","150","","","Percent of Total Billed Charges","neg_dollar:$582.86;150% of Medicaid interim rate","301.60","80","","","Percent of Total Billed Charges","neg_dollar:$301.60;Percent of Total Billed Charges","","","","298.00","Fee Schedule","","196.04","52","","","Percent of Total Billed Charges","neg_dollar:$196.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","196.04","52","","","Percent of Total Billed Charges","neg_dollar:$196.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","196.00","377.00",""
"LUMBOSACR SPINE MIN 4 VIEWS","72110","CPT","70000069","CDM","320","RC","","Facility","Outpatient","","","521","416.80","521.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","521.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","448.06","86","","","Percent of Total Billed Charges","neg_dollar:$448.06","364.70","70","","","Percent of Total Billed Charges","neg_dollar:$364.70","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","306.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$306.08;102% of Medicaid interim rate","390.75","75","","","Percent of Total Billed Charges","neg_dollar:$390.75","448.06","86","","","Percent of Total Billed Charges","neg_dollar:$448.06","364.70","70","","","Percent of Total Billed Charges","neg_dollar:$364.70","296.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$296.96;103.5% of Medicaid interim rate","521.00","150","","","Percent of Total Billed Charges","neg_dollar:$805.49;150% of Medicaid interim rate","416.80","80","","","Percent of Total Billed Charges","neg_dollar:$416.80;Percent of Total Billed Charges","","","","366.00","Fee Schedule","","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","270.00","521.00",""
"CT CERVICAL SPINE WO CONTRAST","72125","CPT","70000070","CDM","352","RC","","Facility","Outpatient","","","2658","2126.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1382.16","52","","","Percent of Total Billed Charges","neg_dollar:$1382.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1382.16","52","","","Percent of Total Billed Charges","neg_dollar:$1382.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1382.16","52","","","Percent of Total Billed Charges","neg_dollar:$1382.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1382.16","52","","","Percent of Total Billed Charges","neg_dollar:$1382.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","2285.88","86","","","Percent of Total Billed Charges","neg_dollar:$2285.88","1860.60","70","","","Percent of Total Billed Charges","neg_dollar:$1860.60","1382.16","52","","","Percent of Total Billed Charges","neg_dollar:$1382.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","1561.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$1561.57;102% of Medicaid interim rate","1993.50","75","","","Percent of Total Billed Charges","neg_dollar:$1993.50","2285.88","86","","","Percent of Total Billed Charges","neg_dollar:$2285.88","1860.60","70","","","Percent of Total Billed Charges","neg_dollar:$1860.60","1515.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$1515.06;103.5% of Medicaid interim rate","2658.00","150","","","Percent of Total Billed Charges","neg_dollar:$4109.40;150% of Medicaid interim rate","2126.40","80","","","Percent of Total Billed Charges","neg_dollar:$2126.40;Percent of Total Billed Charges","","","","2111.00","Fee Schedule","","1382.16","52","","","Percent of Total Billed Charges","neg_dollar:$1382.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","1382.16","52","","","Percent of Total Billed Charges","neg_dollar:$1382.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2658.00",""
"CT CERVICAL SPINE W CONTRAST","72126","CPT","70000071","CDM","352","RC","","Facility","Outpatient","","","3121","2496.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1622.92","52","","","Percent of Total Billed Charges","neg_dollar:$1622.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1622.92","52","","","Percent of Total Billed Charges","neg_dollar:$1622.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1622.92","52","","","Percent of Total Billed Charges","neg_dollar:$1622.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1622.92","52","","","Percent of Total Billed Charges","neg_dollar:$1622.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2684.06","86","","","Percent of Total Billed Charges","neg_dollar:$2684.06","2184.70","70","","","Percent of Total Billed Charges","neg_dollar:$2184.70","1622.92","52","","","Percent of Total Billed Charges","neg_dollar:$1622.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","1833.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$1833.58;102% of Medicaid interim rate","2340.75","75","","","Percent of Total Billed Charges","neg_dollar:$2340.75","2684.06","86","","","Percent of Total Billed Charges","neg_dollar:$2684.06","2184.70","70","","","Percent of Total Billed Charges","neg_dollar:$2184.70","1778.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$1778.96;103.5% of Medicaid interim rate","3121.00","150","","","Percent of Total Billed Charges","neg_dollar:$4825.22;150% of Medicaid interim rate","2496.80","80","","","Percent of Total Billed Charges","neg_dollar:$2496.80;Percent of Total Billed Charges","","","","3121.00","Fee Schedule","","1622.92","52","","","Percent of Total Billed Charges","neg_dollar:$1622.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","1622.92","52","","","Percent of Total Billed Charges","neg_dollar:$1622.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3121.00",""
"CT THORACIC SPINE WO CONTRAST","72128","CPT","70000073","CDM","352","RC","","Facility","Outpatient","","","2527","2021.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2173.22","86","","","Percent of Total Billed Charges","neg_dollar:$2173.22","1768.89","70","","","Percent of Total Billed Charges","neg_dollar:$1768.89","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1484.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$1484.60;102% of Medicaid interim rate","1895.25","75","","","Percent of Total Billed Charges","neg_dollar:$1895.25","2173.22","86","","","Percent of Total Billed Charges","neg_dollar:$2173.22","1768.89","70","","","Percent of Total Billed Charges","neg_dollar:$1768.89","1440.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$1440.38;103.5% of Medicaid interim rate","2527.00","150","","","Percent of Total Billed Charges","neg_dollar:$3906.86;150% of Medicaid interim rate","2021.60","80","","","Percent of Total Billed Charges","neg_dollar:$2021.60;Percent of Total Billed Charges","","","","2109.00","Fee Schedule","","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2527.00",""
"CT THORACIC SPINE W CONTRAST","72129","CPT","70000326","CDM","352","RC","","Facility","Outpatient","","","2990","2392.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2571.40","86","","","Percent of Total Billed Charges","neg_dollar:$2571.40","2093.00","70","","","Percent of Total Billed Charges","neg_dollar:$2093","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","1756.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$1756.62;102% of Medicaid interim rate","2242.50","75","","","Percent of Total Billed Charges","neg_dollar:$2242.50","2571.40","86","","","Percent of Total Billed Charges","neg_dollar:$2571.40","2093.00","70","","","Percent of Total Billed Charges","neg_dollar:$2093","1704.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$1704.30;103.5% of Medicaid interim rate","2990.00","150","","","Percent of Total Billed Charges","neg_dollar:$4622.68;150% of Medicaid interim rate","2392.00","80","","","Percent of Total Billed Charges","neg_dollar:$2392;Percent of Total Billed Charges","","","","2990.00","Fee Schedule","","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2990.00",""
"CT THORACIC SPINE W WO CONTRAST","72130","CPT","70000327","CDM","352","RC","","Facility","Outpatient","","","3774","3019.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1962.48","52","","","Percent of Total Billed Charges","neg_dollar:$1962.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1962.48","52","","","Percent of Total Billed Charges","neg_dollar:$1962.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1962.48","52","","","Percent of Total Billed Charges","neg_dollar:$1962.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1962.48","52","","","Percent of Total Billed Charges","neg_dollar:$1962.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","3245.64","86","","","Percent of Total Billed Charges","neg_dollar:$3245.64","2641.79","70","","","Percent of Total Billed Charges","neg_dollar:$2641.79","1962.48","52","","","Percent of Total Billed Charges","neg_dollar:$1962.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","2217.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$2217.22;102% of Medicaid interim rate","2830.50","75","","","Percent of Total Billed Charges","neg_dollar:$2830.50","3245.64","86","","","Percent of Total Billed Charges","neg_dollar:$3245.64","2641.79","70","","","Percent of Total Billed Charges","neg_dollar:$2641.79","2151.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$2151.18;103.5% of Medicaid interim rate","3774.00","150","","","Percent of Total Billed Charges","neg_dollar:$5834.79;150% of Medicaid interim rate","3019.20","80","","","Percent of Total Billed Charges","neg_dollar:$3019.20;Percent of Total Billed Charges","","","","3774.00","Fee Schedule","","1962.48","52","","","Percent of Total Billed Charges","neg_dollar:$1962.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1962.48","52","","","Percent of Total Billed Charges","neg_dollar:$1962.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3774.00",""
"CT LUMBAR SPINE WO CONTRAST","72131","CPT","70000074","CDM","352","RC","","Facility","Outpatient","","","2527","2021.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2173.22","86","","","Percent of Total Billed Charges","neg_dollar:$2173.22","1768.89","70","","","Percent of Total Billed Charges","neg_dollar:$1768.89","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1484.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$1484.60;102% of Medicaid interim rate","1895.25","75","","","Percent of Total Billed Charges","neg_dollar:$1895.25","2173.22","86","","","Percent of Total Billed Charges","neg_dollar:$2173.22","1768.89","70","","","Percent of Total Billed Charges","neg_dollar:$1768.89","1440.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$1440.38;103.5% of Medicaid interim rate","2527.00","150","","","Percent of Total Billed Charges","neg_dollar:$3906.86;150% of Medicaid interim rate","2021.60","80","","","Percent of Total Billed Charges","neg_dollar:$2021.60;Percent of Total Billed Charges","","","","2007.00","Fee Schedule","","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1314.04","52","","","Percent of Total Billed Charges","neg_dollar:$1314.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2527.00",""
"CT LUMBAR SPINE W CONTRAST","72132","CPT","70000075","CDM","352","RC","","Facility","Outpatient","","","2990","2392.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2571.40","86","","","Percent of Total Billed Charges","neg_dollar:$2571.40","2093.00","70","","","Percent of Total Billed Charges","neg_dollar:$2093","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","1756.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$1756.62;102% of Medicaid interim rate","2242.50","75","","","Percent of Total Billed Charges","neg_dollar:$2242.50","2571.40","86","","","Percent of Total Billed Charges","neg_dollar:$2571.40","2093.00","70","","","Percent of Total Billed Charges","neg_dollar:$2093","1704.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$1704.30;103.5% of Medicaid interim rate","2990.00","150","","","Percent of Total Billed Charges","neg_dollar:$4622.68;150% of Medicaid interim rate","2392.00","80","","","Percent of Total Billed Charges","neg_dollar:$2392;Percent of Total Billed Charges","","","","2990.00","Fee Schedule","","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1554.80","52","","","Percent of Total Billed Charges","neg_dollar:$1554.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2990.00",""
"CT LUMBAR SPINE W WO CONTRAST","72133","CPT","70000076","CDM","352","RC","","Facility","Outpatient","","","3768","3014.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1959.36","52","","","Percent of Total Billed Charges","neg_dollar:$1959.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1959.36","52","","","Percent of Total Billed Charges","neg_dollar:$1959.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1959.36","52","","","Percent of Total Billed Charges","neg_dollar:$1959.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1959.36","52","","","Percent of Total Billed Charges","neg_dollar:$1959.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","3240.48","86","","","Percent of Total Billed Charges","neg_dollar:$3240.48","2637.60","70","","","Percent of Total Billed Charges","neg_dollar:$2637.60","1959.36","52","","","Percent of Total Billed Charges","neg_dollar:$1959.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","2213.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$2213.69;102% of Medicaid interim rate","2826.00","75","","","Percent of Total Billed Charges","neg_dollar:$2826","3240.48","86","","","Percent of Total Billed Charges","neg_dollar:$3240.48","2637.60","70","","","Percent of Total Billed Charges","neg_dollar:$2637.60","2147.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$2147.75;103.5% of Medicaid interim rate","3768.00","150","","","Percent of Total Billed Charges","neg_dollar:$5825.51;150% of Medicaid interim rate","3014.40","80","","","Percent of Total Billed Charges","neg_dollar:$3014.40;Percent of Total Billed Charges","","","","3768.00","Fee Schedule","","1959.36","52","","","Percent of Total Billed Charges","neg_dollar:$1959.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","1959.36","52","","","Percent of Total Billed Charges","neg_dollar:$1959.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3768.00",""
"MRI SPINE CERVICAL WO CONTRAST","72141","CPT","70000077","CDM","612","RC","","Facility","Outpatient","","","3324","2659.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2858.64","86","","","Percent of Total Billed Charges","neg_dollar:$2858.64","2326.79","70","","","Percent of Total Billed Charges","neg_dollar:$2326.79","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","1952.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$1952.84;102% of Medicaid interim rate","2493.00","75","","","Percent of Total Billed Charges","neg_dollar:$2493","2858.64","86","","","Percent of Total Billed Charges","neg_dollar:$2858.64","2326.79","70","","","Percent of Total Billed Charges","neg_dollar:$2326.79","1894.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$1894.67;103.5% of Medicaid interim rate","3324.00","150","","","Percent of Total Billed Charges","neg_dollar:$5139.07;150% of Medicaid interim rate","2659.20","80","","","Percent of Total Billed Charges","neg_dollar:$2659.20;Percent of Total Billed Charges","","","","2641.00","Fee Schedule","","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3324.00",""
"MRI SPINE CERVICAL W CONTRAST","72142","CPT","70000328","CDM","612","RC","","Facility","Outpatient","","","3787","3029.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","3256.82","86","","","Percent of Total Billed Charges","neg_dollar:$3256.82","2650.89","70","","","Percent of Total Billed Charges","neg_dollar:$2650.89","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","2224.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$2224.85;102% of Medicaid interim rate","2840.25","75","","","Percent of Total Billed Charges","neg_dollar:$2840.25","3256.82","86","","","Percent of Total Billed Charges","neg_dollar:$3256.82","2650.89","70","","","Percent of Total Billed Charges","neg_dollar:$2650.89","2158.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$2158.58;103.5% of Medicaid interim rate","3787.00","150","","","Percent of Total Billed Charges","neg_dollar:$5854.89;150% of Medicaid interim rate","3029.60","80","","","Percent of Total Billed Charges","neg_dollar:$3029.60;Percent of Total Billed Charges","","","","3787.00","Fee Schedule","","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3787.00",""
"MRI SPINE THORACIC WO CONTRAST","72146","CPT","70000078","CDM","612","RC","","Facility","Outpatient","","","3324","2659.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2858.64","86","","","Percent of Total Billed Charges","neg_dollar:$2858.64","2326.79","70","","","Percent of Total Billed Charges","neg_dollar:$2326.79","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","1952.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$1952.84;102% of Medicaid interim rate","2493.00","75","","","Percent of Total Billed Charges","neg_dollar:$2493","2858.64","86","","","Percent of Total Billed Charges","neg_dollar:$2858.64","2326.79","70","","","Percent of Total Billed Charges","neg_dollar:$2326.79","1894.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$1894.67;103.5% of Medicaid interim rate","3324.00","150","","","Percent of Total Billed Charges","neg_dollar:$5139.07;150% of Medicaid interim rate","2659.20","80","","","Percent of Total Billed Charges","neg_dollar:$2659.20;Percent of Total Billed Charges","","","","2281.00","Fee Schedule","","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1728.48","52","","","Percent of Total Billed Charges","neg_dollar:$1728.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3324.00",""
"MRI SPINE THORACIC W CONTRAST","72147","CPT","70000329","CDM","612","RC","","Facility","Outpatient","","","3787","3029.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","3256.82","86","","","Percent of Total Billed Charges","neg_dollar:$3256.82","2650.89","70","","","Percent of Total Billed Charges","neg_dollar:$2650.89","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","2224.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$2224.85;102% of Medicaid interim rate","2840.25","75","","","Percent of Total Billed Charges","neg_dollar:$2840.25","3256.82","86","","","Percent of Total Billed Charges","neg_dollar:$3256.82","2650.89","70","","","Percent of Total Billed Charges","neg_dollar:$2650.89","2158.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$2158.58;103.5% of Medicaid interim rate","3787.00","150","","","Percent of Total Billed Charges","neg_dollar:$5854.89;150% of Medicaid interim rate","3029.60","80","","","Percent of Total Billed Charges","neg_dollar:$3029.60;Percent of Total Billed Charges","","","","3787.00","Fee Schedule","","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3787.00",""
"MRI SPINE LUMBAR WO CONTRAST","72148","CPT","70000079","CDM","612","RC","","Facility","Outpatient","","","3407","2725.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1771.64","52","","","Percent of Total Billed Charges","neg_dollar:$1771.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1771.64","52","","","Percent of Total Billed Charges","neg_dollar:$1771.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1771.64","52","","","Percent of Total Billed Charges","neg_dollar:$1771.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1771.64","52","","","Percent of Total Billed Charges","neg_dollar:$1771.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2930.02","86","","","Percent of Total Billed Charges","neg_dollar:$2930.02","2384.89","70","","","Percent of Total Billed Charges","neg_dollar:$2384.89","1771.64","52","","","Percent of Total Billed Charges","neg_dollar:$1771.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","2001.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$2001.60;102% of Medicaid interim rate","2555.25","75","","","Percent of Total Billed Charges","neg_dollar:$2555.25","2930.02","86","","","Percent of Total Billed Charges","neg_dollar:$2930.02","2384.89","70","","","Percent of Total Billed Charges","neg_dollar:$2384.89","1941.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$1941.98;103.5% of Medicaid interim rate","3407.00","150","","","Percent of Total Billed Charges","neg_dollar:$5267.39;150% of Medicaid interim rate","2725.60","80","","","Percent of Total Billed Charges","neg_dollar:$2725.60;Percent of Total Billed Charges","","","","2707.00","Fee Schedule","","1771.64","52","","","Percent of Total Billed Charges","neg_dollar:$1771.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","1771.64","52","","","Percent of Total Billed Charges","neg_dollar:$1771.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3407.00",""
"MRI SPINE LUMBAR W CONTRAST","72149","CPT","70000330","CDM","612","RC","","Facility","Outpatient","","","3870","3096.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2012.40","52","","","Percent of Total Billed Charges","neg_dollar:$2012.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2012.40","52","","","Percent of Total Billed Charges","neg_dollar:$2012.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2012.40","52","","","Percent of Total Billed Charges","neg_dollar:$2012.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2012.40","52","","","Percent of Total Billed Charges","neg_dollar:$2012.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","3328.20","86","","","Percent of Total Billed Charges","neg_dollar:$3328.20","2709.00","70","","","Percent of Total Billed Charges","neg_dollar:$2709","2012.40","52","","","Percent of Total Billed Charges","neg_dollar:$2012.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","2273.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2273.62;102% of Medicaid interim rate","2902.50","75","","","Percent of Total Billed Charges","neg_dollar:$2902.50","3328.20","86","","","Percent of Total Billed Charges","neg_dollar:$3328.20","2709.00","70","","","Percent of Total Billed Charges","neg_dollar:$2709","2205.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$2205.89;103.5% of Medicaid interim rate","3870.00","150","","","Percent of Total Billed Charges","neg_dollar:$5983.21;150% of Medicaid interim rate","3096.00","80","","","Percent of Total Billed Charges","neg_dollar:$3096;Percent of Total Billed Charges","","","","3870.00","Fee Schedule","","2012.40","52","","","Percent of Total Billed Charges","neg_dollar:$2012.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","2012.40","52","","","Percent of Total Billed Charges","neg_dollar:$2012.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3870.00",""
"MRI SPINE CERVICAL W WO CONTRAST","72156","CPT","70000080","CDM","612","RC","","Facility","Outpatient","","","4328","3462.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2250.56","52","","","Percent of Total Billed Charges","neg_dollar:$2250.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2250.56","52","","","Percent of Total Billed Charges","neg_dollar:$2250.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","2250.56","52","","","Percent of Total Billed Charges","neg_dollar:$2250.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","2250.56","52","","","Percent of Total Billed Charges","neg_dollar:$2250.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","3722.08","86","","","Percent of Total Billed Charges","neg_dollar:$3722.08","3029.60","70","","","Percent of Total Billed Charges","neg_dollar:$3029.60","2250.56","52","","","Percent of Total Billed Charges","neg_dollar:$2250.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","2542.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$2542.69;102% of Medicaid interim rate","3246.00","75","","","Percent of Total Billed Charges","neg_dollar:$3246","3722.08","86","","","Percent of Total Billed Charges","neg_dollar:$3722.08","3029.60","70","","","Percent of Total Billed Charges","neg_dollar:$3029.60","2466.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$2466.95;103.5% of Medicaid interim rate","4328.00","150","","","Percent of Total Billed Charges","neg_dollar:$6691.30;150% of Medicaid interim rate","3462.40","80","","","Percent of Total Billed Charges","neg_dollar:$3462.40;Percent of Total Billed Charges","","","","2897.00","Fee Schedule","","2250.56","52","","","Percent of Total Billed Charges","neg_dollar:$2250.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","2250.56","52","","","Percent of Total Billed Charges","neg_dollar:$2250.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4328.00",""
"MRI SPINE THORACIC W WO CONTRAST","72157","CPT","70000081","CDM","612","RC","","Facility","Outpatient","","","4250","3400.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2210.00","52","","","Percent of Total Billed Charges","neg_dollar:$2210;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2210.00","52","","","Percent of Total Billed Charges","neg_dollar:$2210;102% Medicare Outpatient Cost to Charge Ratio of 52%","2210.00","52","","","Percent of Total Billed Charges","neg_dollar:$2210;102% Medicare Outpatient Cost to Charge Ratio of 52%","2210.00","52","","","Percent of Total Billed Charges","neg_dollar:$2210;102% Medicare Outpatient Cost to Charge Ratio of 52%","3655.00","86","","","Percent of Total Billed Charges","neg_dollar:$3655","2975.00","70","","","Percent of Total Billed Charges","neg_dollar:$2975","2210.00","52","","","Percent of Total Billed Charges","neg_dollar:$2210;105% Medicare Outpatient Cost to Charge Ratio of 52%","2496.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$2496.87;102% of Medicaid interim rate","3187.50","75","","","Percent of Total Billed Charges","neg_dollar:$3187.50","3655.00","86","","","Percent of Total Billed Charges","neg_dollar:$3655","2975.00","70","","","Percent of Total Billed Charges","neg_dollar:$2975","2422.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$2422.50;103.5% of Medicaid interim rate","4250.00","150","","","Percent of Total Billed Charges","neg_dollar:$6570.71;150% of Medicaid interim rate","3400.00","80","","","Percent of Total Billed Charges","neg_dollar:$3400;Percent of Total Billed Charges","","","","3547.00","Fee Schedule","","2210.00","52","","","Percent of Total Billed Charges","neg_dollar:$2210;100% Medicare Outpatient Cost to Charge Ratio of 52%","2210.00","52","","","Percent of Total Billed Charges","neg_dollar:$2210;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4250.00",""
"MRI SPINE LUMBAR W WO CONTRAST","72158","CPT","70000082","CDM","612","RC","","Facility","Outpatient","","","4333","3466.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2253.16","52","","","Percent of Total Billed Charges","neg_dollar:$2253.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2253.16","52","","","Percent of Total Billed Charges","neg_dollar:$2253.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","2253.16","52","","","Percent of Total Billed Charges","neg_dollar:$2253.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","2253.16","52","","","Percent of Total Billed Charges","neg_dollar:$2253.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","3726.38","86","","","Percent of Total Billed Charges","neg_dollar:$3726.38","3033.10","70","","","Percent of Total Billed Charges","neg_dollar:$3033.10","2253.16","52","","","Percent of Total Billed Charges","neg_dollar:$2253.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","2545.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$2545.63;102% of Medicaid interim rate","3249.75","75","","","Percent of Total Billed Charges","neg_dollar:$3249.75","3726.38","86","","","Percent of Total Billed Charges","neg_dollar:$3726.38","3033.10","70","","","Percent of Total Billed Charges","neg_dollar:$3033.10","2469.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$2469.81;103.5% of Medicaid interim rate","4333.00","150","","","Percent of Total Billed Charges","neg_dollar:$6699.03;150% of Medicaid interim rate","3466.40","80","","","Percent of Total Billed Charges","neg_dollar:$3466.40;Percent of Total Billed Charges","","","","3443.00","Fee Schedule","","2253.16","52","","","Percent of Total Billed Charges","neg_dollar:$2253.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","2253.16","52","","","Percent of Total Billed Charges","neg_dollar:$2253.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4333.00",""
"MRA W/DYE SPINAL CANAL","72159","CPT","70000288","CDM","610","RC","","Facility","Outpatient","","","3574","2859.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1858.48","52","","","Percent of Total Billed Charges","neg_dollar:$1858.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1858.48","52","","","Percent of Total Billed Charges","neg_dollar:$1858.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1858.48","52","","","Percent of Total Billed Charges","neg_dollar:$1858.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1858.48","52","","","Percent of Total Billed Charges","neg_dollar:$1858.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","3073.64","86","","","Percent of Total Billed Charges","neg_dollar:$3073.64","2501.79","70","","","Percent of Total Billed Charges","neg_dollar:$2501.79","1858.48","52","","","Percent of Total Billed Charges","neg_dollar:$1858.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","2099.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$2099.72;102% of Medicaid interim rate","2680.50","75","","","Percent of Total Billed Charges","neg_dollar:$2680.50","3073.64","86","","","Percent of Total Billed Charges","neg_dollar:$3073.64","2501.79","70","","","Percent of Total Billed Charges","neg_dollar:$2501.79","2037.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$2037.17;103.5% of Medicaid interim rate","3574.00","150","","","Percent of Total Billed Charges","neg_dollar:$5525.58;150% of Medicaid interim rate","2859.20","80","","","Percent of Total Billed Charges","neg_dollar:$2859.20;Percent of Total Billed Charges","","","","3574.00","Fee Schedule","","1858.48","52","","","Percent of Total Billed Charges","neg_dollar:$1858.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1858.48","52","","","Percent of Total Billed Charges","neg_dollar:$1858.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3574.00",""
"MRA W/O DYE SPINAL CANAL","72159","CPT","70000289","CDM","610","RC","","Facility","Outpatient","","","3432","2745.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1784.64","52","","","Percent of Total Billed Charges","neg_dollar:$1784.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1784.64","52","","","Percent of Total Billed Charges","neg_dollar:$1784.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1784.64","52","","","Percent of Total Billed Charges","neg_dollar:$1784.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1784.64","52","","","Percent of Total Billed Charges","neg_dollar:$1784.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2951.52","86","","","Percent of Total Billed Charges","neg_dollar:$2951.52","2402.39","70","","","Percent of Total Billed Charges","neg_dollar:$2402.39","1784.64","52","","","Percent of Total Billed Charges","neg_dollar:$1784.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","2016.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$2016.29;102% of Medicaid interim rate","2574.00","75","","","Percent of Total Billed Charges","neg_dollar:$2574","2951.52","86","","","Percent of Total Billed Charges","neg_dollar:$2951.52","2402.39","70","","","Percent of Total Billed Charges","neg_dollar:$2402.39","1956.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1956.23;103.5% of Medicaid interim rate","3432.00","150","","","Percent of Total Billed Charges","neg_dollar:$5306.04;150% of Medicaid interim rate","2745.60","80","","","Percent of Total Billed Charges","neg_dollar:$2745.60;Percent of Total Billed Charges","","","","3432.00","Fee Schedule","","1784.64","52","","","Percent of Total Billed Charges","neg_dollar:$1784.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","1784.64","52","","","Percent of Total Billed Charges","neg_dollar:$1784.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3432.00",""
"PELVIS 1 OR  2 VIEWS","72170","CPT","70000083","CDM","320","RC","","Facility","Outpatient","","","276","220.80","276.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","143.52","52","","","Percent of Total Billed Charges","neg_dollar:$143.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","276.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","143.52","52","","","Percent of Total Billed Charges","neg_dollar:$143.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","143.52","52","","","Percent of Total Billed Charges","neg_dollar:$143.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","143.52","52","","","Percent of Total Billed Charges","neg_dollar:$143.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","237.35","86","","","Percent of Total Billed Charges","neg_dollar:$237.35","193.20","70","","","Percent of Total Billed Charges","neg_dollar:$193.20","143.52","52","","","Percent of Total Billed Charges","neg_dollar:$143.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","162.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$162.14;102% of Medicaid interim rate","207.00","75","","","Percent of Total Billed Charges","neg_dollar:$207","237.35","86","","","Percent of Total Billed Charges","neg_dollar:$237.35","193.20","70","","","Percent of Total Billed Charges","neg_dollar:$193.20","157.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$157.32;103.5% of Medicaid interim rate","276.00","150","","","Percent of Total Billed Charges","neg_dollar:$426.70;150% of Medicaid interim rate","220.80","80","","","Percent of Total Billed Charges","neg_dollar:$220.80;Percent of Total Billed Charges","","","","230.00","Fee Schedule","","143.52","52","","","Percent of Total Billed Charges","neg_dollar:$143.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","143.52","52","","","Percent of Total Billed Charges","neg_dollar:$143.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","143.00","276.00",""
"PELVIS MIN 3 VIEWS","72190","CPT","70000084","CDM","320","RC","","Facility","Outpatient","","","341","272.80","341.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","177.32","52","","","Percent of Total Billed Charges","neg_dollar:$177.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","341.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","177.32","52","","","Percent of Total Billed Charges","neg_dollar:$177.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","177.32","52","","","Percent of Total Billed Charges","neg_dollar:$177.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","177.32","52","","","Percent of Total Billed Charges","neg_dollar:$177.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.26","86","","","Percent of Total Billed Charges","neg_dollar:$293.26","238.70","70","","","Percent of Total Billed Charges","neg_dollar:$238.70","177.32","52","","","Percent of Total Billed Charges","neg_dollar:$177.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","200.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$200.33;102% of Medicaid interim rate","255.75","75","","","Percent of Total Billed Charges","neg_dollar:$255.75","293.26","86","","","Percent of Total Billed Charges","neg_dollar:$293.26","238.70","70","","","Percent of Total Billed Charges","neg_dollar:$238.70","194.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$194.36;103.5% of Medicaid interim rate","341.00","150","","","Percent of Total Billed Charges","neg_dollar:$527.20;150% of Medicaid interim rate","272.80","80","","","Percent of Total Billed Charges","neg_dollar:$272.80;Percent of Total Billed Charges","","","","234.00","Fee Schedule","","177.32","52","","","Percent of Total Billed Charges","neg_dollar:$177.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","177.32","52","","","Percent of Total Billed Charges","neg_dollar:$177.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","177.00","341.00",""
"CT PELVIS WO CONTRAST","72192","CPT","70000086","CDM","352","RC","","Facility","Outpatient","","","2406","1924.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1251.12","52","","","Percent of Total Billed Charges","neg_dollar:$1251.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1251.12","52","","","Percent of Total Billed Charges","neg_dollar:$1251.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","1251.12","52","","","Percent of Total Billed Charges","neg_dollar:$1251.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","1251.12","52","","","Percent of Total Billed Charges","neg_dollar:$1251.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","2069.16","86","","","Percent of Total Billed Charges","neg_dollar:$2069.16","1684.19","70","","","Percent of Total Billed Charges","neg_dollar:$1684.19","1251.12","52","","","Percent of Total Billed Charges","neg_dollar:$1251.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","1413.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$1413.52;102% of Medicaid interim rate","1804.50","75","","","Percent of Total Billed Charges","neg_dollar:$1804.50","2069.16","86","","","Percent of Total Billed Charges","neg_dollar:$2069.16","1684.19","70","","","Percent of Total Billed Charges","neg_dollar:$1684.19","1371.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$1371.41;103.5% of Medicaid interim rate","2406.00","150","","","Percent of Total Billed Charges","neg_dollar:$3719.79;150% of Medicaid interim rate","1924.80","80","","","Percent of Total Billed Charges","neg_dollar:$1924.80;Percent of Total Billed Charges","","","","1911.00","Fee Schedule","","1251.12","52","","","Percent of Total Billed Charges","neg_dollar:$1251.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","1251.12","52","","","Percent of Total Billed Charges","neg_dollar:$1251.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2406.00",""
"CT PELVIS W CONTRAST","72193","CPT","70000087","CDM","352","RC","","Facility","Outpatient","","","2961","2368.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1539.72","52","","","Percent of Total Billed Charges","neg_dollar:$1539.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1539.72","52","","","Percent of Total Billed Charges","neg_dollar:$1539.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1539.72","52","","","Percent of Total Billed Charges","neg_dollar:$1539.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1539.72","52","","","Percent of Total Billed Charges","neg_dollar:$1539.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","2546.46","86","","","Percent of Total Billed Charges","neg_dollar:$2546.46","2072.70","70","","","Percent of Total Billed Charges","neg_dollar:$2072.70","1539.72","52","","","Percent of Total Billed Charges","neg_dollar:$1539.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","1739.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$1739.58;102% of Medicaid interim rate","2220.75","75","","","Percent of Total Billed Charges","neg_dollar:$2220.75","2546.46","86","","","Percent of Total Billed Charges","neg_dollar:$2546.46","2072.70","70","","","Percent of Total Billed Charges","neg_dollar:$2072.70","1687.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$1687.76;103.5% of Medicaid interim rate","2961.00","150","","","Percent of Total Billed Charges","neg_dollar:$4577.85;150% of Medicaid interim rate","2368.80","80","","","Percent of Total Billed Charges","neg_dollar:$2368.80;Percent of Total Billed Charges","","","","2961.00","Fee Schedule","","1539.72","52","","","Percent of Total Billed Charges","neg_dollar:$1539.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1539.72","52","","","Percent of Total Billed Charges","neg_dollar:$1539.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2961.00",""
"CT PELVIS W WO CONTRAST","72194","CPT","70000088","CDM","352","RC","","Facility","Outpatient","","","3424","2739.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1780.48","52","","","Percent of Total Billed Charges","neg_dollar:$1780.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1780.48","52","","","Percent of Total Billed Charges","neg_dollar:$1780.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1780.48","52","","","Percent of Total Billed Charges","neg_dollar:$1780.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1780.48","52","","","Percent of Total Billed Charges","neg_dollar:$1780.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2944.64","86","","","Percent of Total Billed Charges","neg_dollar:$2944.64","2396.79","70","","","Percent of Total Billed Charges","neg_dollar:$2396.79","1780.48","52","","","Percent of Total Billed Charges","neg_dollar:$1780.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","2011.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$2011.59;102% of Medicaid interim rate","2568.00","75","","","Percent of Total Billed Charges","neg_dollar:$2568","2944.64","86","","","Percent of Total Billed Charges","neg_dollar:$2944.64","2396.79","70","","","Percent of Total Billed Charges","neg_dollar:$2396.79","1951.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$1951.67;103.5% of Medicaid interim rate","3424.00","150","","","Percent of Total Billed Charges","neg_dollar:$5293.67;150% of Medicaid interim rate","2739.20","80","","","Percent of Total Billed Charges","neg_dollar:$2739.20;Percent of Total Billed Charges","","","","3424.00","Fee Schedule","","1780.48","52","","","Percent of Total Billed Charges","neg_dollar:$1780.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1780.48","52","","","Percent of Total Billed Charges","neg_dollar:$1780.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3424.00",""
"MRI PELVIS WO CONTRAST","72195","CPT","70000331","CDM","610","RC","","Facility","Outpatient","","","3288","2630.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2827.68","86","","","Percent of Total Billed Charges","neg_dollar:$2827.68","2301.60","70","","","Percent of Total Billed Charges","neg_dollar:$2301.60","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","1931.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$1931.69;102% of Medicaid interim rate","2466.00","75","","","Percent of Total Billed Charges","neg_dollar:$2466","2827.68","86","","","Percent of Total Billed Charges","neg_dollar:$2827.68","2301.60","70","","","Percent of Total Billed Charges","neg_dollar:$2301.60","1874.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$1874.15;103.5% of Medicaid interim rate","3288.00","150","","","Percent of Total Billed Charges","neg_dollar:$5083.41;150% of Medicaid interim rate","2630.40","80","","","Percent of Total Billed Charges","neg_dollar:$2630.40;Percent of Total Billed Charges","","","","2201.00","Fee Schedule","","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3288.00",""
"MRI PELVIS W CONTRAST","72196","CPT","70000089","CDM","610","RC","","Facility","Outpatient","","","4192","3353.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2179.84","52","","","Percent of Total Billed Charges","neg_dollar:$2179.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2179.84","52","","","Percent of Total Billed Charges","neg_dollar:$2179.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","2179.84","52","","","Percent of Total Billed Charges","neg_dollar:$2179.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","2179.84","52","","","Percent of Total Billed Charges","neg_dollar:$2179.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","3605.12","86","","","Percent of Total Billed Charges","neg_dollar:$3605.12","2934.39","70","","","Percent of Total Billed Charges","neg_dollar:$2934.39","2179.84","52","","","Percent of Total Billed Charges","neg_dollar:$2179.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","2462.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$2462.79;102% of Medicaid interim rate","3144.00","75","","","Percent of Total Billed Charges","neg_dollar:$3144","3605.12","86","","","Percent of Total Billed Charges","neg_dollar:$3605.12","2934.39","70","","","Percent of Total Billed Charges","neg_dollar:$2934.39","2389.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$2389.43;103.5% of Medicaid interim rate","4192.00","150","","","Percent of Total Billed Charges","neg_dollar:$6481.04;150% of Medicaid interim rate","3353.60","80","","","Percent of Total Billed Charges","neg_dollar:$3353.60;Percent of Total Billed Charges","","","","4192.00","Fee Schedule","","2179.84","52","","","Percent of Total Billed Charges","neg_dollar:$2179.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","2179.84","52","","","Percent of Total Billed Charges","neg_dollar:$2179.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4192.00",""
"MRI PELVIS W WO CONTRAST","72197","CPT","70000090","CDM","610","RC","","Facility","Outpatient","","","5109","4087.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","4393.74","86","","","Percent of Total Billed Charges","neg_dollar:$4393.74","3576.29","70","","","Percent of Total Billed Charges","neg_dollar:$3576.29","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","3001.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$3001.53;102% of Medicaid interim rate","3831.75","75","","","Percent of Total Billed Charges","neg_dollar:$3831.75","4393.74","86","","","Percent of Total Billed Charges","neg_dollar:$4393.74","3576.29","70","","","Percent of Total Billed Charges","neg_dollar:$3576.29","2912.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$2912.12;103.5% of Medicaid interim rate","5109.00","150","","","Percent of Total Billed Charges","neg_dollar:$7898.76;150% of Medicaid interim rate","4087.20","80","","","Percent of Total Billed Charges","neg_dollar:$4087.20;Percent of Total Billed Charges","","","","3421.00","Fee Schedule","","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5109.00",""
"MRA PELVIS W CONTRAST","72198","CPT","70000332","CDM","610","RC","","Facility","Outpatient","","","5067","4053.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2634.84","52","","","Percent of Total Billed Charges","neg_dollar:$2634.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2634.84","52","","","Percent of Total Billed Charges","neg_dollar:$2634.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","2634.84","52","","","Percent of Total Billed Charges","neg_dollar:$2634.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","2634.84","52","","","Percent of Total Billed Charges","neg_dollar:$2634.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","4357.62","86","","","Percent of Total Billed Charges","neg_dollar:$4357.62","3546.89","70","","","Percent of Total Billed Charges","neg_dollar:$3546.89","2634.84","52","","","Percent of Total Billed Charges","neg_dollar:$2634.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","2976.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$2976.85;102% of Medicaid interim rate","3800.25","75","","","Percent of Total Billed Charges","neg_dollar:$3800.25","4357.62","86","","","Percent of Total Billed Charges","neg_dollar:$4357.62","3546.89","70","","","Percent of Total Billed Charges","neg_dollar:$3546.89","2888.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$2888.18;103.5% of Medicaid interim rate","5067.00","150","","","Percent of Total Billed Charges","neg_dollar:$7833.83;150% of Medicaid interim rate","4053.60","80","","","Percent of Total Billed Charges","neg_dollar:$4053.60;Percent of Total Billed Charges","","","","5067.00","Fee Schedule","","2634.84","52","","","Percent of Total Billed Charges","neg_dollar:$2634.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","2634.84","52","","","Percent of Total Billed Charges","neg_dollar:$2634.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5067.00",""
"MRA PELVIS W WO CONTRAST","72198","CPT","70000617","CDM","610","RC","","Facility","Outpatient","","","4692","3753.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2439.84","52","","","Percent of Total Billed Charges","neg_dollar:$2439.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2439.84","52","","","Percent of Total Billed Charges","neg_dollar:$2439.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","2439.84","52","","","Percent of Total Billed Charges","neg_dollar:$2439.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","2439.84","52","","","Percent of Total Billed Charges","neg_dollar:$2439.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","4035.12","86","","","Percent of Total Billed Charges","neg_dollar:$4035.12","3284.39","70","","","Percent of Total Billed Charges","neg_dollar:$3284.39","2439.84","52","","","Percent of Total Billed Charges","neg_dollar:$2439.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","2756.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$2756.54;102% of Medicaid interim rate","3519.00","75","","","Percent of Total Billed Charges","neg_dollar:$3519","4035.12","86","","","Percent of Total Billed Charges","neg_dollar:$4035.12","3284.39","70","","","Percent of Total Billed Charges","neg_dollar:$3284.39","2674.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$2674.43;103.5% of Medicaid interim rate","4692.00","150","","","Percent of Total Billed Charges","neg_dollar:$7254.06;150% of Medicaid interim rate","3753.60","80","","","Percent of Total Billed Charges","neg_dollar:$3753.60;Percent of Total Billed Charges","","","","4692.00","Fee Schedule","","2439.84","52","","","Percent of Total Billed Charges","neg_dollar:$2439.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","2439.84","52","","","Percent of Total Billed Charges","neg_dollar:$2439.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4692.00",""
"MRA PELVIS WO CONTRAST","72198","CPT","70000620","CDM","610","RC","","Facility","Outpatient","","","3288","2630.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2827.68","86","","","Percent of Total Billed Charges","neg_dollar:$2827.68","2301.60","70","","","Percent of Total Billed Charges","neg_dollar:$2301.60","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","1931.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$1931.69;102% of Medicaid interim rate","2466.00","75","","","Percent of Total Billed Charges","neg_dollar:$2466","2827.68","86","","","Percent of Total Billed Charges","neg_dollar:$2827.68","2301.60","70","","","Percent of Total Billed Charges","neg_dollar:$2301.60","1874.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$1874.15;103.5% of Medicaid interim rate","3288.00","150","","","Percent of Total Billed Charges","neg_dollar:$5083.41;150% of Medicaid interim rate","2630.40","80","","","Percent of Total Billed Charges","neg_dollar:$2630.40;Percent of Total Billed Charges","","","","3288.00","Fee Schedule","","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1709.76","52","","","Percent of Total Billed Charges","neg_dollar:$1709.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3288.00",""
"SI JOINTS MIN 3 VIEWS","72202","CPT","70000091","CDM","320","RC","","Facility","Outpatient","","","405","324.00","405.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","210.60","52","","","Percent of Total Billed Charges","neg_dollar:$210.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","405.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","210.60","52","","","Percent of Total Billed Charges","neg_dollar:$210.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.60","52","","","Percent of Total Billed Charges","neg_dollar:$210.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.60","52","","","Percent of Total Billed Charges","neg_dollar:$210.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","348.30","86","","","Percent of Total Billed Charges","neg_dollar:$348.30","283.50","70","","","Percent of Total Billed Charges","neg_dollar:$283.50","210.60","52","","","Percent of Total Billed Charges","neg_dollar:$210.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","237.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.93;102% of Medicaid interim rate","303.75","75","","","Percent of Total Billed Charges","neg_dollar:$303.75","348.30","86","","","Percent of Total Billed Charges","neg_dollar:$348.30","283.50","70","","","Percent of Total Billed Charges","neg_dollar:$283.50","230.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.85;103.5% of Medicaid interim rate","405.00","150","","","Percent of Total Billed Charges","neg_dollar:$626.15;150% of Medicaid interim rate","324.00","80","","","Percent of Total Billed Charges","neg_dollar:$324;Percent of Total Billed Charges","","","","329.00","Fee Schedule","","210.60","52","","","Percent of Total Billed Charges","neg_dollar:$210.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.60","52","","","Percent of Total Billed Charges","neg_dollar:$210.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","405.00",""
"SACRUM COCCYX MIN 2 VIEWS","72220","CPT","70000092","CDM","320","RC","","Facility","Outpatient","","","321","256.80","321.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","166.92","52","","","Percent of Total Billed Charges","neg_dollar:$166.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","321.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","166.92","52","","","Percent of Total Billed Charges","neg_dollar:$166.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","166.92","52","","","Percent of Total Billed Charges","neg_dollar:$166.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","166.92","52","","","Percent of Total Billed Charges","neg_dollar:$166.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","276.06","86","","","Percent of Total Billed Charges","neg_dollar:$276.06","224.70","70","","","Percent of Total Billed Charges","neg_dollar:$224.70","166.92","52","","","Percent of Total Billed Charges","neg_dollar:$166.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","188.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$188.58;102% of Medicaid interim rate","240.75","75","","","Percent of Total Billed Charges","neg_dollar:$240.75","276.06","86","","","Percent of Total Billed Charges","neg_dollar:$276.06","224.70","70","","","Percent of Total Billed Charges","neg_dollar:$224.70","182.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$182.96;103.5% of Medicaid interim rate","321.00","150","","","Percent of Total Billed Charges","neg_dollar:$496.28;150% of Medicaid interim rate","256.80","80","","","Percent of Total Billed Charges","neg_dollar:$256.80;Percent of Total Billed Charges","","","","268.00","Fee Schedule","","166.92","52","","","Percent of Total Billed Charges","neg_dollar:$166.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","166.92","52","","","Percent of Total Billed Charges","neg_dollar:$166.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","166.00","321.00",""
"CLAVICLE COMPLETE","73000","CPT","70000098","CDM","320","RC","","Facility","Outpatient","","","364","291.20","364.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","189.28","52","","","Percent of Total Billed Charges","neg_dollar:$189.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","364.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","189.28","52","","","Percent of Total Billed Charges","neg_dollar:$189.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","189.28","52","","","Percent of Total Billed Charges","neg_dollar:$189.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","189.28","52","","","Percent of Total Billed Charges","neg_dollar:$189.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","313.04","86","","","Percent of Total Billed Charges","neg_dollar:$313.04","254.79","70","","","Percent of Total Billed Charges","neg_dollar:$254.79","189.28","52","","","Percent of Total Billed Charges","neg_dollar:$189.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","213.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$213.84;102% of Medicaid interim rate","273.00","75","","","Percent of Total Billed Charges","neg_dollar:$273","313.04","86","","","Percent of Total Billed Charges","neg_dollar:$313.04","254.79","70","","","Percent of Total Billed Charges","neg_dollar:$254.79","207.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$207.48;103.5% of Medicaid interim rate","364.00","150","","","Percent of Total Billed Charges","neg_dollar:$562.76;150% of Medicaid interim rate","291.20","80","","","Percent of Total Billed Charges","neg_dollar:$291.20;Percent of Total Billed Charges","","","","364.00","Fee Schedule","","189.28","52","","","Percent of Total Billed Charges","neg_dollar:$189.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","189.28","52","","","Percent of Total Billed Charges","neg_dollar:$189.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","189.00","364.00",""
"SCAPULA COMPL","73010","CPT","70000099","CDM","320","RC","","Facility","Outpatient","","","407","325.60","407.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","407.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","350.02","86","","","Percent of Total Billed Charges","neg_dollar:$350.02","284.90","70","","","Percent of Total Billed Charges","neg_dollar:$284.90","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","239.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$239.11;102% of Medicaid interim rate","305.25","75","","","Percent of Total Billed Charges","neg_dollar:$305.25","350.02","86","","","Percent of Total Billed Charges","neg_dollar:$350.02","284.90","70","","","Percent of Total Billed Charges","neg_dollar:$284.90","231.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$231.98;103.5% of Medicaid interim rate","407.00","150","","","Percent of Total Billed Charges","neg_dollar:$629.24;150% of Medicaid interim rate","325.60","80","","","Percent of Total Billed Charges","neg_dollar:$325.60;Percent of Total Billed Charges","","","","407.00","Fee Schedule","","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","211.00","407.00",""
"SHOULDER 1 VIEW","73020","CPT","70000100","CDM","320","RC","","Facility","Outpatient","","","249","199.20","249.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","129.48","52","","","Percent of Total Billed Charges","neg_dollar:$129.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","249.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","129.48","52","","","Percent of Total Billed Charges","neg_dollar:$129.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","129.48","52","","","Percent of Total Billed Charges","neg_dollar:$129.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","129.48","52","","","Percent of Total Billed Charges","neg_dollar:$129.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","214.14","86","","","Percent of Total Billed Charges","neg_dollar:$214.14","174.29","70","","","Percent of Total Billed Charges","neg_dollar:$174.29","129.48","52","","","Percent of Total Billed Charges","neg_dollar:$129.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","146.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$146.28;102% of Medicaid interim rate","186.75","75","","","Percent of Total Billed Charges","neg_dollar:$186.75","214.14","86","","","Percent of Total Billed Charges","neg_dollar:$214.14","174.29","70","","","Percent of Total Billed Charges","neg_dollar:$174.29","141.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$141.92;103.5% of Medicaid interim rate","249.00","150","","","Percent of Total Billed Charges","neg_dollar:$384.96;150% of Medicaid interim rate","199.20","80","","","Percent of Total Billed Charges","neg_dollar:$199.20;Percent of Total Billed Charges","","","","249.00","Fee Schedule","","129.48","52","","","Percent of Total Billed Charges","neg_dollar:$129.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","129.48","52","","","Percent of Total Billed Charges","neg_dollar:$129.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","129.00","249.00",""
"SHOULDER MIN 2 VIEWS","73030","CPT","70000101","CDM","320","RC","","Facility","Outpatient","","","375","300.00","375.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","195.00","52","","","Percent of Total Billed Charges","neg_dollar:$195;101% Medicare Outpatient Cost to Charge Ratio of 52%","375.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","195.00","52","","","Percent of Total Billed Charges","neg_dollar:$195;102% Medicare Outpatient Cost to Charge Ratio of 52%","195.00","52","","","Percent of Total Billed Charges","neg_dollar:$195;102% Medicare Outpatient Cost to Charge Ratio of 52%","195.00","52","","","Percent of Total Billed Charges","neg_dollar:$195;102% Medicare Outpatient Cost to Charge Ratio of 52%","322.50","86","","","Percent of Total Billed Charges","neg_dollar:$322.50","262.50","70","","","Percent of Total Billed Charges","neg_dollar:$262.50","195.00","52","","","Percent of Total Billed Charges","neg_dollar:$195;105% Medicare Outpatient Cost to Charge Ratio of 52%","220.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$220.31;102% of Medicaid interim rate","281.25","75","","","Percent of Total Billed Charges","neg_dollar:$281.25","322.50","86","","","Percent of Total Billed Charges","neg_dollar:$322.50","262.50","70","","","Percent of Total Billed Charges","neg_dollar:$262.50","213.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$213.74;103.5% of Medicaid interim rate","375.00","150","","","Percent of Total Billed Charges","neg_dollar:$579.76;150% of Medicaid interim rate","300.00","80","","","Percent of Total Billed Charges","neg_dollar:$300;Percent of Total Billed Charges","","","","375.00","Fee Schedule","","195.00","52","","","Percent of Total Billed Charges","neg_dollar:$195;100% Medicare Outpatient Cost to Charge Ratio of 52%","195.00","52","","","Percent of Total Billed Charges","neg_dollar:$195;100% Medicare Outpatient Cost to Charge Ratio of 52%","195.00","375.00",""
"ACJ BILATERAL W WO WEIGHTS","73050","CPT","70000103","CDM","320","RC","","Facility","Outpatient","","","412","329.60","412.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","214.24","52","","","Percent of Total Billed Charges","neg_dollar:$214.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","412.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","214.24","52","","","Percent of Total Billed Charges","neg_dollar:$214.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","214.24","52","","","Percent of Total Billed Charges","neg_dollar:$214.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","214.24","52","","","Percent of Total Billed Charges","neg_dollar:$214.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","354.32","86","","","Percent of Total Billed Charges","neg_dollar:$354.32","288.40","70","","","Percent of Total Billed Charges","neg_dollar:$288.40","214.24","52","","","Percent of Total Billed Charges","neg_dollar:$214.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","242.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$242.04;102% of Medicaid interim rate","309.00","75","","","Percent of Total Billed Charges","neg_dollar:$309","354.32","86","","","Percent of Total Billed Charges","neg_dollar:$354.32","288.40","70","","","Percent of Total Billed Charges","neg_dollar:$288.40","234.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$234.83;103.5% of Medicaid interim rate","412.00","150","","","Percent of Total Billed Charges","neg_dollar:$636.97;150% of Medicaid interim rate","329.60","80","","","Percent of Total Billed Charges","neg_dollar:$329.60;Percent of Total Billed Charges","","","","412.00","Fee Schedule","","214.24","52","","","Percent of Total Billed Charges","neg_dollar:$214.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","214.24","52","","","Percent of Total Billed Charges","neg_dollar:$214.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","214.00","412.00",""
"HUMERUS MIN 2 VIEWS","73060","CPT","70000104","CDM","320","RC","","Facility","Outpatient","","","306","244.80","306.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","306.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","263.15","86","","","Percent of Total Billed Charges","neg_dollar:$263.15","214.20","70","","","Percent of Total Billed Charges","neg_dollar:$214.20","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","179.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$179.77;102% of Medicaid interim rate","229.50","75","","","Percent of Total Billed Charges","neg_dollar:$229.50","263.15","86","","","Percent of Total Billed Charges","neg_dollar:$263.15","214.20","70","","","Percent of Total Billed Charges","neg_dollar:$214.20","174.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$174.42;103.5% of Medicaid interim rate","306.00","150","","","Percent of Total Billed Charges","neg_dollar:$473.09;150% of Medicaid interim rate","244.80","80","","","Percent of Total Billed Charges","neg_dollar:$244.80;Percent of Total Billed Charges","","","","306.00","Fee Schedule","","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","159.00","306.00",""
"ELBOW 2 VIEWS","73070","CPT","70000105","CDM","320","RC","","Facility","Outpatient","","","274","219.20","274.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","274.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","235.64","86","","","Percent of Total Billed Charges","neg_dollar:$235.64","191.79","70","","","Percent of Total Billed Charges","neg_dollar:$191.79","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","160.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$160.97;102% of Medicaid interim rate","205.50","75","","","Percent of Total Billed Charges","neg_dollar:$205.50","235.64","86","","","Percent of Total Billed Charges","neg_dollar:$235.64","191.79","70","","","Percent of Total Billed Charges","neg_dollar:$191.79","156.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$156.17;103.5% of Medicaid interim rate","274.00","150","","","Percent of Total Billed Charges","neg_dollar:$423.61;150% of Medicaid interim rate","219.20","80","","","Percent of Total Billed Charges","neg_dollar:$219.20;Percent of Total Billed Charges","","","","274.00","Fee Schedule","","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","142.00","274.00",""
"ELBOW MIN 3 VIEWS","73080","CPT","70000106","CDM","320","RC","","Facility","Outpatient","","","358","286.40","358.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","358.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","307.88","86","","","Percent of Total Billed Charges","neg_dollar:$307.88","250.60","70","","","Percent of Total Billed Charges","neg_dollar:$250.60","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","210.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$210.32;102% of Medicaid interim rate","268.50","75","","","Percent of Total Billed Charges","neg_dollar:$268.50","307.88","86","","","Percent of Total Billed Charges","neg_dollar:$307.88","250.60","70","","","Percent of Total Billed Charges","neg_dollar:$250.60","204.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$204.05;103.5% of Medicaid interim rate","358.00","150","","","Percent of Total Billed Charges","neg_dollar:$553.48;150% of Medicaid interim rate","286.40","80","","","Percent of Total Billed Charges","neg_dollar:$286.40;Percent of Total Billed Charges","","","","358.00","Fee Schedule","","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","186.16","52","","","Percent of Total Billed Charges","neg_dollar:$186.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","186.00","358.00",""
"FOREARM 2 VIEWS","73090","CPT","70000108","CDM","320","RC","","Facility","Outpatient","","","337","269.60","337.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","175.24","52","","","Percent of Total Billed Charges","neg_dollar:$175.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","337.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","175.24","52","","","Percent of Total Billed Charges","neg_dollar:$175.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","175.24","52","","","Percent of Total Billed Charges","neg_dollar:$175.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","175.24","52","","","Percent of Total Billed Charges","neg_dollar:$175.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","289.82","86","","","Percent of Total Billed Charges","neg_dollar:$289.82","235.89","70","","","Percent of Total Billed Charges","neg_dollar:$235.89","175.24","52","","","Percent of Total Billed Charges","neg_dollar:$175.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","197.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$197.98;102% of Medicaid interim rate","252.75","75","","","Percent of Total Billed Charges","neg_dollar:$252.75","289.82","86","","","Percent of Total Billed Charges","neg_dollar:$289.82","235.89","70","","","Percent of Total Billed Charges","neg_dollar:$235.89","192.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$192.08;103.5% of Medicaid interim rate","337.00","150","","","Percent of Total Billed Charges","neg_dollar:$521.01;150% of Medicaid interim rate","269.60","80","","","Percent of Total Billed Charges","neg_dollar:$269.60;Percent of Total Billed Charges","","","","337.00","Fee Schedule","","175.24","52","","","Percent of Total Billed Charges","neg_dollar:$175.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","175.24","52","","","Percent of Total Billed Charges","neg_dollar:$175.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","175.00","337.00",""
"UPPR EXTR INFANT MIN 2 VIEWS","73092","CPT","70000109","CDM","320","RC","","Facility","Outpatient","","","359","287.20","359.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","186.68","52","","","Percent of Total Billed Charges","neg_dollar:$186.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","359.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","186.68","52","","","Percent of Total Billed Charges","neg_dollar:$186.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","186.68","52","","","Percent of Total Billed Charges","neg_dollar:$186.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","186.68","52","","","Percent of Total Billed Charges","neg_dollar:$186.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","308.74","86","","","Percent of Total Billed Charges","neg_dollar:$308.74","251.29","70","","","Percent of Total Billed Charges","neg_dollar:$251.29","186.68","52","","","Percent of Total Billed Charges","neg_dollar:$186.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","210.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$210.91;102% of Medicaid interim rate","269.25","75","","","Percent of Total Billed Charges","neg_dollar:$269.25","308.74","86","","","Percent of Total Billed Charges","neg_dollar:$308.74","251.29","70","","","Percent of Total Billed Charges","neg_dollar:$251.29","204.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$204.63;103.5% of Medicaid interim rate","359.00","150","","","Percent of Total Billed Charges","neg_dollar:$555.03;150% of Medicaid interim rate","287.20","80","","","Percent of Total Billed Charges","neg_dollar:$287.20;Percent of Total Billed Charges","","","","359.00","Fee Schedule","","186.68","52","","","Percent of Total Billed Charges","neg_dollar:$186.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","186.68","52","","","Percent of Total Billed Charges","neg_dollar:$186.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","186.00","359.00",""
"WRIST 2 VIEWS","73100","CPT","70000110","CDM","320","RC","","Facility","Outpatient","","","291","232.80","291.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","151.32","52","","","Percent of Total Billed Charges","neg_dollar:$151.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","291.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","151.32","52","","","Percent of Total Billed Charges","neg_dollar:$151.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","151.32","52","","","Percent of Total Billed Charges","neg_dollar:$151.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","151.32","52","","","Percent of Total Billed Charges","neg_dollar:$151.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","250.26","86","","","Percent of Total Billed Charges","neg_dollar:$250.26","203.70","70","","","Percent of Total Billed Charges","neg_dollar:$203.70","151.32","52","","","Percent of Total Billed Charges","neg_dollar:$151.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","170.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$170.96;102% of Medicaid interim rate","218.25","75","","","Percent of Total Billed Charges","neg_dollar:$218.25","250.26","86","","","Percent of Total Billed Charges","neg_dollar:$250.26","203.70","70","","","Percent of Total Billed Charges","neg_dollar:$203.70","165.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$165.86;103.5% of Medicaid interim rate","291.00","150","","","Percent of Total Billed Charges","neg_dollar:$449.90;150% of Medicaid interim rate","232.80","80","","","Percent of Total Billed Charges","neg_dollar:$232.80;Percent of Total Billed Charges","","","","291.00","Fee Schedule","","151.32","52","","","Percent of Total Billed Charges","neg_dollar:$151.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","151.32","52","","","Percent of Total Billed Charges","neg_dollar:$151.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","151.00","291.00",""
"WRIST COMPL MIN 3 VIEWS","73110","CPT","70000111","CDM","320","RC","","Facility","Outpatient","","","343","274.40","343.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","178.36","52","","","Percent of Total Billed Charges","neg_dollar:$178.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","343.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","178.36","52","","","Percent of Total Billed Charges","neg_dollar:$178.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","178.36","52","","","Percent of Total Billed Charges","neg_dollar:$178.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","178.36","52","","","Percent of Total Billed Charges","neg_dollar:$178.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","294.98","86","","","Percent of Total Billed Charges","neg_dollar:$294.98","240.10","70","","","Percent of Total Billed Charges","neg_dollar:$240.10","178.36","52","","","Percent of Total Billed Charges","neg_dollar:$178.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","201.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$201.51;102% of Medicaid interim rate","257.25","75","","","Percent of Total Billed Charges","neg_dollar:$257.25","294.98","86","","","Percent of Total Billed Charges","neg_dollar:$294.98","240.10","70","","","Percent of Total Billed Charges","neg_dollar:$240.10","195.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$195.51;103.5% of Medicaid interim rate","343.00","150","","","Percent of Total Billed Charges","neg_dollar:$530.29;150% of Medicaid interim rate","274.40","80","","","Percent of Total Billed Charges","neg_dollar:$274.40;Percent of Total Billed Charges","","","","343.00","Fee Schedule","","178.36","52","","","Percent of Total Billed Charges","neg_dollar:$178.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","178.36","52","","","Percent of Total Billed Charges","neg_dollar:$178.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","178.00","343.00",""
"HAND 2 VIEWS","73120","CPT","70000113","CDM","320","RC","","Facility","Outpatient","","","316","252.80","316.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","164.32","52","","","Percent of Total Billed Charges","neg_dollar:$164.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","316.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","164.32","52","","","Percent of Total Billed Charges","neg_dollar:$164.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","164.32","52","","","Percent of Total Billed Charges","neg_dollar:$164.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","164.32","52","","","Percent of Total Billed Charges","neg_dollar:$164.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","271.76","86","","","Percent of Total Billed Charges","neg_dollar:$271.76","221.20","70","","","Percent of Total Billed Charges","neg_dollar:$221.20","164.32","52","","","Percent of Total Billed Charges","neg_dollar:$164.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","185.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$185.64;102% of Medicaid interim rate","237.00","75","","","Percent of Total Billed Charges","neg_dollar:$237","271.76","86","","","Percent of Total Billed Charges","neg_dollar:$271.76","221.20","70","","","Percent of Total Billed Charges","neg_dollar:$221.20","180.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$180.11;103.5% of Medicaid interim rate","316.00","150","","","Percent of Total Billed Charges","neg_dollar:$488.55;150% of Medicaid interim rate","252.80","80","","","Percent of Total Billed Charges","neg_dollar:$252.80;Percent of Total Billed Charges","","","","316.00","Fee Schedule","","164.32","52","","","Percent of Total Billed Charges","neg_dollar:$164.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","164.32","52","","","Percent of Total Billed Charges","neg_dollar:$164.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","164.00","316.00",""
"HAND MIN 3 VIEWS","73130","CPT","70000114","CDM","320","RC","","Facility","Outpatient","","","340","272.00","340.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","340.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","292.40","86","","","Percent of Total Billed Charges","neg_dollar:$292.40","237.99","70","","","Percent of Total Billed Charges","neg_dollar:$237.99","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","199.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$199.74;102% of Medicaid interim rate","255.00","75","","","Percent of Total Billed Charges","neg_dollar:$255","292.40","86","","","Percent of Total Billed Charges","neg_dollar:$292.40","237.99","70","","","Percent of Total Billed Charges","neg_dollar:$237.99","193.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$193.79;103.5% of Medicaid interim rate","340.00","150","","","Percent of Total Billed Charges","neg_dollar:$525.65;150% of Medicaid interim rate","272.00","80","","","Percent of Total Billed Charges","neg_dollar:$272;Percent of Total Billed Charges","","","","340.00","Fee Schedule","","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","176.00","340.00",""
"FINGER OR FINGERS MIN 2 VIEWS","73140","CPT","70000115","CDM","320","RC","","Facility","Outpatient","","","295","236.00","295.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","153.40","52","","","Percent of Total Billed Charges","neg_dollar:$153.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","295.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","153.40","52","","","Percent of Total Billed Charges","neg_dollar:$153.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","153.40","52","","","Percent of Total Billed Charges","neg_dollar:$153.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","153.40","52","","","Percent of Total Billed Charges","neg_dollar:$153.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","253.70","86","","","Percent of Total Billed Charges","neg_dollar:$253.70","206.50","70","","","Percent of Total Billed Charges","neg_dollar:$206.50","153.40","52","","","Percent of Total Billed Charges","neg_dollar:$153.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","173.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$173.31;102% of Medicaid interim rate","221.25","75","","","Percent of Total Billed Charges","neg_dollar:$221.25","253.70","86","","","Percent of Total Billed Charges","neg_dollar:$253.70","206.50","70","","","Percent of Total Billed Charges","neg_dollar:$206.50","168.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$168.14;103.5% of Medicaid interim rate","295.00","150","","","Percent of Total Billed Charges","neg_dollar:$456.08;150% of Medicaid interim rate","236.00","80","","","Percent of Total Billed Charges","neg_dollar:$236;Percent of Total Billed Charges","","","","295.00","Fee Schedule","","153.40","52","","","Percent of Total Billed Charges","neg_dollar:$153.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","153.40","52","","","Percent of Total Billed Charges","neg_dollar:$153.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","153.00","295.00",""
"CT UPPER EXTR WO CONTRAST","73200","CPT","70000116","CDM","352","RC","","Facility","Outpatient","","","2607","2085.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1355.64","52","","","Percent of Total Billed Charges","neg_dollar:$1355.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1355.64","52","","","Percent of Total Billed Charges","neg_dollar:$1355.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1355.64","52","","","Percent of Total Billed Charges","neg_dollar:$1355.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1355.64","52","","","Percent of Total Billed Charges","neg_dollar:$1355.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2242.02","86","","","Percent of Total Billed Charges","neg_dollar:$2242.02","1824.89","70","","","Percent of Total Billed Charges","neg_dollar:$1824.89","1355.64","52","","","Percent of Total Billed Charges","neg_dollar:$1355.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","1531.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$1531.60;102% of Medicaid interim rate","1955.25","75","","","Percent of Total Billed Charges","neg_dollar:$1955.25","2242.02","86","","","Percent of Total Billed Charges","neg_dollar:$2242.02","1824.89","70","","","Percent of Total Billed Charges","neg_dollar:$1824.89","1485.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$1485.98;103.5% of Medicaid interim rate","2607.00","150","","","Percent of Total Billed Charges","neg_dollar:$4030.55;150% of Medicaid interim rate","2085.60","80","","","Percent of Total Billed Charges","neg_dollar:$2085.60;Percent of Total Billed Charges","","","","2607.00","Fee Schedule","","1355.64","52","","","Percent of Total Billed Charges","neg_dollar:$1355.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","1355.64","52","","","Percent of Total Billed Charges","neg_dollar:$1355.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2607.00",""
"CT UPPER EXTR W CONTRAST","73201","CPT","70000117","CDM","352","RC","","Facility","Outpatient","","","3070","2456.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1596.40","52","","","Percent of Total Billed Charges","neg_dollar:$1596.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1596.40","52","","","Percent of Total Billed Charges","neg_dollar:$1596.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1596.40","52","","","Percent of Total Billed Charges","neg_dollar:$1596.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1596.40","52","","","Percent of Total Billed Charges","neg_dollar:$1596.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2640.20","86","","","Percent of Total Billed Charges","neg_dollar:$2640.20","2149.00","70","","","Percent of Total Billed Charges","neg_dollar:$2149","1596.40","52","","","Percent of Total Billed Charges","neg_dollar:$1596.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","1803.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$1803.62;102% of Medicaid interim rate","2302.50","75","","","Percent of Total Billed Charges","neg_dollar:$2302.50","2640.20","86","","","Percent of Total Billed Charges","neg_dollar:$2640.20","2149.00","70","","","Percent of Total Billed Charges","neg_dollar:$2149","1749.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$1749.89;103.5% of Medicaid interim rate","3070.00","150","","","Percent of Total Billed Charges","neg_dollar:$4746.37;150% of Medicaid interim rate","2456.00","80","","","Percent of Total Billed Charges","neg_dollar:$2456;Percent of Total Billed Charges","","","","3070.00","Fee Schedule","","1596.40","52","","","Percent of Total Billed Charges","neg_dollar:$1596.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1596.40","52","","","Percent of Total Billed Charges","neg_dollar:$1596.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3070.00",""
"CT UPPER EXTR W WO CONTRAST","73202","CPT","70000337","CDM","352","RC","","Facility","Outpatient","","","3533","2826.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1837.16","52","","","Percent of Total Billed Charges","neg_dollar:$1837.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1837.16","52","","","Percent of Total Billed Charges","neg_dollar:$1837.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1837.16","52","","","Percent of Total Billed Charges","neg_dollar:$1837.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1837.16","52","","","Percent of Total Billed Charges","neg_dollar:$1837.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","3038.38","86","","","Percent of Total Billed Charges","neg_dollar:$3038.38","2473.10","70","","","Percent of Total Billed Charges","neg_dollar:$2473.10","1837.16","52","","","Percent of Total Billed Charges","neg_dollar:$1837.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","2075.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$2075.63;102% of Medicaid interim rate","2649.75","75","","","Percent of Total Billed Charges","neg_dollar:$2649.75","3038.38","86","","","Percent of Total Billed Charges","neg_dollar:$3038.38","2473.10","70","","","Percent of Total Billed Charges","neg_dollar:$2473.10","2013.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$2013.80;103.5% of Medicaid interim rate","3533.00","150","","","Percent of Total Billed Charges","neg_dollar:$5462.19;150% of Medicaid interim rate","2826.40","80","","","Percent of Total Billed Charges","neg_dollar:$2826.40;Percent of Total Billed Charges","","","","3533.00","Fee Schedule","","1837.16","52","","","Percent of Total Billed Charges","neg_dollar:$1837.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","1837.16","52","","","Percent of Total Billed Charges","neg_dollar:$1837.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3533.00",""
"MRI UP EXTR NOT JOINT WO CONTRAST","73218","CPT","70000119","CDM","610","RC","","Facility","Outpatient","","","3373","2698.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1753.96","52","","","Percent of Total Billed Charges","neg_dollar:$1753.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1753.96","52","","","Percent of Total Billed Charges","neg_dollar:$1753.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1753.96","52","","","Percent of Total Billed Charges","neg_dollar:$1753.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1753.96","52","","","Percent of Total Billed Charges","neg_dollar:$1753.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","2900.77","86","","","Percent of Total Billed Charges","neg_dollar:$2900.77","2361.10","70","","","Percent of Total Billed Charges","neg_dollar:$2361.10","1753.96","52","","","Percent of Total Billed Charges","neg_dollar:$1753.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","1981.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$1981.63;102% of Medicaid interim rate","2529.75","75","","","Percent of Total Billed Charges","neg_dollar:$2529.75","2900.77","86","","","Percent of Total Billed Charges","neg_dollar:$2900.77","2361.10","70","","","Percent of Total Billed Charges","neg_dollar:$2361.10","1922.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$1922.61;103.5% of Medicaid interim rate","3373.00","150","","","Percent of Total Billed Charges","neg_dollar:$5214.82;150% of Medicaid interim rate","2698.40","80","","","Percent of Total Billed Charges","neg_dollar:$2698.40;Percent of Total Billed Charges","","","","3373.00","Fee Schedule","","1753.96","52","","","Percent of Total Billed Charges","neg_dollar:$1753.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","1753.96","52","","","Percent of Total Billed Charges","neg_dollar:$1753.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3373.00",""
"MRI UP EXTR NOT JOINT W WO CONTR","73220","CPT","70000121","CDM","610","RC","","Facility","Outpatient","","","5109","4087.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","4393.74","86","","","Percent of Total Billed Charges","neg_dollar:$4393.74","3576.29","70","","","Percent of Total Billed Charges","neg_dollar:$3576.29","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","3001.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$3001.53;102% of Medicaid interim rate","3831.75","75","","","Percent of Total Billed Charges","neg_dollar:$3831.75","4393.74","86","","","Percent of Total Billed Charges","neg_dollar:$4393.74","3576.29","70","","","Percent of Total Billed Charges","neg_dollar:$3576.29","2912.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$2912.12;103.5% of Medicaid interim rate","5109.00","150","","","Percent of Total Billed Charges","neg_dollar:$7898.76;150% of Medicaid interim rate","4087.20","80","","","Percent of Total Billed Charges","neg_dollar:$4087.20;Percent of Total Billed Charges","","","","5109.00","Fee Schedule","","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5109.00",""
"MRI UP EXTR ANY JOINT WO CONTRAST","73221","CPT","70000122","CDM","610","RC","","Facility","Outpatient","","","3203","2562.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1665.56","52","","","Percent of Total Billed Charges","neg_dollar:$1665.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1665.56","52","","","Percent of Total Billed Charges","neg_dollar:$1665.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1665.56","52","","","Percent of Total Billed Charges","neg_dollar:$1665.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1665.56","52","","","Percent of Total Billed Charges","neg_dollar:$1665.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","2754.58","86","","","Percent of Total Billed Charges","neg_dollar:$2754.58","2242.10","70","","","Percent of Total Billed Charges","neg_dollar:$2242.10","1665.56","52","","","Percent of Total Billed Charges","neg_dollar:$1665.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","1881.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$1881.75;102% of Medicaid interim rate","2402.25","75","","","Percent of Total Billed Charges","neg_dollar:$2402.25","2754.58","86","","","Percent of Total Billed Charges","neg_dollar:$2754.58","2242.10","70","","","Percent of Total Billed Charges","neg_dollar:$2242.10","1825.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$1825.70;103.5% of Medicaid interim rate","3203.00","150","","","Percent of Total Billed Charges","neg_dollar:$4951.99;150% of Medicaid interim rate","2562.40","80","","","Percent of Total Billed Charges","neg_dollar:$2562.40;Percent of Total Billed Charges","","","","3203.00","Fee Schedule","","1665.56","52","","","Percent of Total Billed Charges","neg_dollar:$1665.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1665.56","52","","","Percent of Total Billed Charges","neg_dollar:$1665.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3203.00",""
"MRI UP EXTR ANY JOINT W CONTRAST","73222","CPT","70000123","CDM","610","RC","","Facility","Outpatient","","","3666","2932.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1906.32","52","","","Percent of Total Billed Charges","neg_dollar:$1906.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1906.32","52","","","Percent of Total Billed Charges","neg_dollar:$1906.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1906.32","52","","","Percent of Total Billed Charges","neg_dollar:$1906.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1906.32","52","","","Percent of Total Billed Charges","neg_dollar:$1906.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","3152.75","86","","","Percent of Total Billed Charges","neg_dollar:$3152.75","2566.20","70","","","Percent of Total Billed Charges","neg_dollar:$2566.20","1906.32","52","","","Percent of Total Billed Charges","neg_dollar:$1906.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","2153.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$2153.77;102% of Medicaid interim rate","2749.50","75","","","Percent of Total Billed Charges","neg_dollar:$2749.50","3152.75","86","","","Percent of Total Billed Charges","neg_dollar:$3152.75","2566.20","70","","","Percent of Total Billed Charges","neg_dollar:$2566.20","2089.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2089.62;103.5% of Medicaid interim rate","3666.00","150","","","Percent of Total Billed Charges","neg_dollar:$5667.81;150% of Medicaid interim rate","2932.80","80","","","Percent of Total Billed Charges","neg_dollar:$2932.80;Percent of Total Billed Charges","","","","3666.00","Fee Schedule","","1906.32","52","","","Percent of Total Billed Charges","neg_dollar:$1906.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","1906.32","52","","","Percent of Total Billed Charges","neg_dollar:$1906.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3666.00",""
"MRI UP EXTR ANY JOINT W WO CONTR","73223","CPT","70000338","CDM","610","RC","","Facility","Outpatient","","","4995","3996.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2597.40","52","","","Percent of Total Billed Charges","neg_dollar:$2597.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2597.40","52","","","Percent of Total Billed Charges","neg_dollar:$2597.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2597.40","52","","","Percent of Total Billed Charges","neg_dollar:$2597.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2597.40","52","","","Percent of Total Billed Charges","neg_dollar:$2597.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","4295.70","86","","","Percent of Total Billed Charges","neg_dollar:$4295.70","3496.50","70","","","Percent of Total Billed Charges","neg_dollar:$3496.50","2597.40","52","","","Percent of Total Billed Charges","neg_dollar:$2597.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","2934.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$2934.55;102% of Medicaid interim rate","3746.25","75","","","Percent of Total Billed Charges","neg_dollar:$3746.25","4295.70","86","","","Percent of Total Billed Charges","neg_dollar:$4295.70","3496.50","70","","","Percent of Total Billed Charges","neg_dollar:$3496.50","2847.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$2847.14;103.5% of Medicaid interim rate","4995.00","150","","","Percent of Total Billed Charges","neg_dollar:$7722.51;150% of Medicaid interim rate","3996.00","80","","","Percent of Total Billed Charges","neg_dollar:$3996;Percent of Total Billed Charges","","","","4995.00","Fee Schedule","","2597.40","52","","","Percent of Total Billed Charges","neg_dollar:$2597.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","2597.40","52","","","Percent of Total Billed Charges","neg_dollar:$2597.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4995.00",""
"MRA W/DYE UPPER EXTREMITY","73225","CPT","70000291","CDM","610","RC","","Facility","Outpatient","","","3628","2902.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1886.56","52","","","Percent of Total Billed Charges","neg_dollar:$1886.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1886.56","52","","","Percent of Total Billed Charges","neg_dollar:$1886.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1886.56","52","","","Percent of Total Billed Charges","neg_dollar:$1886.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1886.56","52","","","Percent of Total Billed Charges","neg_dollar:$1886.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","3120.08","86","","","Percent of Total Billed Charges","neg_dollar:$3120.08","2539.60","70","","","Percent of Total Billed Charges","neg_dollar:$2539.60","1886.56","52","","","Percent of Total Billed Charges","neg_dollar:$1886.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","2131.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$2131.44;102% of Medicaid interim rate","2721.00","75","","","Percent of Total Billed Charges","neg_dollar:$2721","3120.08","86","","","Percent of Total Billed Charges","neg_dollar:$3120.08","2539.60","70","","","Percent of Total Billed Charges","neg_dollar:$2539.60","2067.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$2067.96;103.5% of Medicaid interim rate","3628.00","150","","","Percent of Total Billed Charges","neg_dollar:$5609.06;150% of Medicaid interim rate","2902.40","80","","","Percent of Total Billed Charges","neg_dollar:$2902.40;Percent of Total Billed Charges","","","","3628.00","Fee Schedule","","1886.56","52","","","Percent of Total Billed Charges","neg_dollar:$1886.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1886.56","52","","","Percent of Total Billed Charges","neg_dollar:$1886.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3628.00",""
"MRA W/O DYE UPPER EXTR","73225","CPT","70000292","CDM","610","RC","","Facility","Outpatient","","","3488","2790.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1813.76","52","","","Percent of Total Billed Charges","neg_dollar:$1813.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1813.76","52","","","Percent of Total Billed Charges","neg_dollar:$1813.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1813.76","52","","","Percent of Total Billed Charges","neg_dollar:$1813.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1813.76","52","","","Percent of Total Billed Charges","neg_dollar:$1813.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2999.68","86","","","Percent of Total Billed Charges","neg_dollar:$2999.68","2441.60","70","","","Percent of Total Billed Charges","neg_dollar:$2441.60","1813.76","52","","","Percent of Total Billed Charges","neg_dollar:$1813.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","2049.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$2049.19;102% of Medicaid interim rate","2616.00","75","","","Percent of Total Billed Charges","neg_dollar:$2616","2999.68","86","","","Percent of Total Billed Charges","neg_dollar:$2999.68","2441.60","70","","","Percent of Total Billed Charges","neg_dollar:$2441.60","1988.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$1988.15;103.5% of Medicaid interim rate","3488.00","150","","","Percent of Total Billed Charges","neg_dollar:$5392.62;150% of Medicaid interim rate","2790.40","80","","","Percent of Total Billed Charges","neg_dollar:$2790.40;Percent of Total Billed Charges","","","","3488.00","Fee Schedule","","1813.76","52","","","Percent of Total Billed Charges","neg_dollar:$1813.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1813.76","52","","","Percent of Total Billed Charges","neg_dollar:$1813.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3488.00",""
"MRA W/O&W/DYE UPPER EXTR","73225","CPT","70000293","CDM","610","RC","","Facility","Outpatient","","","3770","3016.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1960.40","52","","","Percent of Total Billed Charges","neg_dollar:$1960.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1960.40","52","","","Percent of Total Billed Charges","neg_dollar:$1960.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1960.40","52","","","Percent of Total Billed Charges","neg_dollar:$1960.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1960.40","52","","","Percent of Total Billed Charges","neg_dollar:$1960.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","3242.20","86","","","Percent of Total Billed Charges","neg_dollar:$3242.20","2639.00","70","","","Percent of Total Billed Charges","neg_dollar:$2639","1960.40","52","","","Percent of Total Billed Charges","neg_dollar:$1960.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","2214.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$2214.87;102% of Medicaid interim rate","2827.50","75","","","Percent of Total Billed Charges","neg_dollar:$2827.50","3242.20","86","","","Percent of Total Billed Charges","neg_dollar:$3242.20","2639.00","70","","","Percent of Total Billed Charges","neg_dollar:$2639","2148.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$2148.89;103.5% of Medicaid interim rate","3770.00","150","","","Percent of Total Billed Charges","neg_dollar:$5828.60;150% of Medicaid interim rate","3016.00","80","","","Percent of Total Billed Charges","neg_dollar:$3016;Percent of Total Billed Charges","","","","3770.00","Fee Schedule","","1960.40","52","","","Percent of Total Billed Charges","neg_dollar:$1960.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1960.40","52","","","Percent of Total Billed Charges","neg_dollar:$1960.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3770.00",""
"X-RAY EXAM HIP UNI 1 VIEW","73501","CPT","70000754","CDM","320","RC","","Facility","Outpatient","","","259","207.20","259.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","259.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","222.74","86","","","Percent of Total Billed Charges","neg_dollar:$222.74","181.29","70","","","Percent of Total Billed Charges","neg_dollar:$181.29","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","152.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$152.16;102% of Medicaid interim rate","194.25","75","","","Percent of Total Billed Charges","neg_dollar:$194.25","222.74","86","","","Percent of Total Billed Charges","neg_dollar:$222.74","181.29","70","","","Percent of Total Billed Charges","neg_dollar:$181.29","147.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$147.63;103.5% of Medicaid interim rate","259.00","150","","","Percent of Total Billed Charges","neg_dollar:$400.42;150% of Medicaid interim rate","207.20","80","","","Percent of Total Billed Charges","neg_dollar:$207.20;Percent of Total Billed Charges","","","","259.00","Fee Schedule","","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","134.00","259.00",""
"X-RAY EXAM HIP UNI 2-3 VIEWS","73502","CPT","70000755","CDM","320","RC","","Facility","Outpatient","","","340","272.00","340.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","340.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","292.40","86","","","Percent of Total Billed Charges","neg_dollar:$292.40","237.99","70","","","Percent of Total Billed Charges","neg_dollar:$237.99","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","199.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$199.74;102% of Medicaid interim rate","255.00","75","","","Percent of Total Billed Charges","neg_dollar:$255","292.40","86","","","Percent of Total Billed Charges","neg_dollar:$292.40","237.99","70","","","Percent of Total Billed Charges","neg_dollar:$237.99","193.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$193.79;103.5% of Medicaid interim rate","340.00","150","","","Percent of Total Billed Charges","neg_dollar:$525.65;150% of Medicaid interim rate","272.00","80","","","Percent of Total Billed Charges","neg_dollar:$272;Percent of Total Billed Charges","","","","340.00","Fee Schedule","","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","176.80","52","","","Percent of Total Billed Charges","neg_dollar:$176.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","176.00","340.00",""
"X-RAY EXAM HIP UNI 4/> VIEWS","73503","CPT","70000756","CDM","320","RC","","Facility","Outpatient","","","424","339.20","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","249.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.09;102% of Medicaid interim rate","318.00","75","","","Percent of Total Billed Charges","neg_dollar:$318","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","241.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$241.67;103.5% of Medicaid interim rate","424.00","150","","","Percent of Total Billed Charges","neg_dollar:$655.52;150% of Medicaid interim rate","339.20","80","","","Percent of Total Billed Charges","neg_dollar:$339.20;Percent of Total Billed Charges","","","","424.00","Fee Schedule","","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.00","424.00",""
"X-RAY EXAM HIPS BI 2 VIEWS","73521","CPT","70000757","CDM","320","RC","","Facility","Outpatient","","","448","358.40","448.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","448.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","385.28","86","","","Percent of Total Billed Charges","neg_dollar:$385.28","313.59","70","","","Percent of Total Billed Charges","neg_dollar:$313.59","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","263.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$263.19;102% of Medicaid interim rate","336.00","75","","","Percent of Total Billed Charges","neg_dollar:$336","385.28","86","","","Percent of Total Billed Charges","neg_dollar:$385.28","313.59","70","","","Percent of Total Billed Charges","neg_dollar:$313.59","255.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$255.35;103.5% of Medicaid interim rate","448.00","150","","","Percent of Total Billed Charges","neg_dollar:$692.63;150% of Medicaid interim rate","358.40","80","","","Percent of Total Billed Charges","neg_dollar:$358.40;Percent of Total Billed Charges","","","","448.00","Fee Schedule","","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","232.00","448.00",""
"X-RAY EXAM HIPS BI 3-4 VIEWS","73522","CPT","70000758","CDM","320","RC","","Facility","Outpatient","","","494","395.20","494.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","494.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","424.84","86","","","Percent of Total Billed Charges","neg_dollar:$424.84","345.79","70","","","Percent of Total Billed Charges","neg_dollar:$345.79","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","290.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$290.22;102% of Medicaid interim rate","370.50","75","","","Percent of Total Billed Charges","neg_dollar:$370.50","424.84","86","","","Percent of Total Billed Charges","neg_dollar:$424.84","345.79","70","","","Percent of Total Billed Charges","neg_dollar:$345.79","281.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$281.58;103.5% of Medicaid interim rate","494.00","150","","","Percent of Total Billed Charges","neg_dollar:$763.74;150% of Medicaid interim rate","395.20","80","","","Percent of Total Billed Charges","neg_dollar:$395.20;Percent of Total Billed Charges","","","","391.00","Fee Schedule","","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","256.00","494.00",""
"X-RAY EXAM HIPS BI 5/> VIEWS","73523","CPT","70000759","CDM","320","RC","","Facility","Outpatient","","","564","451.20","564.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","564.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","331.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$331.34;102% of Medicaid interim rate","423.00","75","","","Percent of Total Billed Charges","neg_dollar:$423","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","321.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$321.47;103.5% of Medicaid interim rate","564.00","150","","","Percent of Total Billed Charges","neg_dollar:$871.97;150% of Medicaid interim rate","451.20","80","","","Percent of Total Billed Charges","neg_dollar:$451.20;Percent of Total Billed Charges","","","","564.00","Fee Schedule","","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","293.00","564.00",""
"X-RAY EXAM OF FEMUR 1 VW","73551","CPT","70000760","CDM","320","RC","","Facility","Outpatient","","","240","192.00","240.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","240.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","206.40","86","","","Percent of Total Billed Charges","neg_dollar:$206.40","168.00","70","","","Percent of Total Billed Charges","neg_dollar:$168","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","140.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$140.99;102% of Medicaid interim rate","180.00","75","","","Percent of Total Billed Charges","neg_dollar:$180","206.40","86","","","Percent of Total Billed Charges","neg_dollar:$206.40","168.00","70","","","Percent of Total Billed Charges","neg_dollar:$168","136.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$136.79;103.5% of Medicaid interim rate","240.00","150","","","Percent of Total Billed Charges","neg_dollar:$371.05;150% of Medicaid interim rate","192.00","80","","","Percent of Total Billed Charges","neg_dollar:$192;Percent of Total Billed Charges","","","","240.00","Fee Schedule","","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","124.00","240.00",""
"X-RAY EXAM OF FEMUR 2/> VW","73552","CPT","70000761","CDM","320","RC","","Facility","Outpatient","","","312","249.60","312.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","312.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","268.32","86","","","Percent of Total Billed Charges","neg_dollar:$268.32","218.39","70","","","Percent of Total Billed Charges","neg_dollar:$218.39","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","183.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$183.29;102% of Medicaid interim rate","234.00","75","","","Percent of Total Billed Charges","neg_dollar:$234","268.32","86","","","Percent of Total Billed Charges","neg_dollar:$268.32","218.39","70","","","Percent of Total Billed Charges","neg_dollar:$218.39","177.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$177.83;103.5% of Medicaid interim rate","312.00","150","","","Percent of Total Billed Charges","neg_dollar:$482.36;150% of Medicaid interim rate","249.60","80","","","Percent of Total Billed Charges","neg_dollar:$249.60;Percent of Total Billed Charges","","","","312.00","Fee Schedule","","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.00","312.00",""
"KNEE 1 OR 2 VIEWS","73560","CPT","70000130","CDM","320","RC","","Facility","Outpatient","","","315","252.00","315.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","163.80","52","","","Percent of Total Billed Charges","neg_dollar:$163.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","315.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","163.80","52","","","Percent of Total Billed Charges","neg_dollar:$163.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","163.80","52","","","Percent of Total Billed Charges","neg_dollar:$163.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","163.80","52","","","Percent of Total Billed Charges","neg_dollar:$163.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","270.90","86","","","Percent of Total Billed Charges","neg_dollar:$270.90","220.50","70","","","Percent of Total Billed Charges","neg_dollar:$220.50","163.80","52","","","Percent of Total Billed Charges","neg_dollar:$163.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","185.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$185.06;102% of Medicaid interim rate","236.25","75","","","Percent of Total Billed Charges","neg_dollar:$236.25","270.90","86","","","Percent of Total Billed Charges","neg_dollar:$270.90","220.50","70","","","Percent of Total Billed Charges","neg_dollar:$220.50","179.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$179.54;103.5% of Medicaid interim rate","315.00","150","","","Percent of Total Billed Charges","neg_dollar:$487;150% of Medicaid interim rate","252.00","80","","","Percent of Total Billed Charges","neg_dollar:$252;Percent of Total Billed Charges","","","","315.00","Fee Schedule","","163.80","52","","","Percent of Total Billed Charges","neg_dollar:$163.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","163.80","52","","","Percent of Total Billed Charges","neg_dollar:$163.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","163.00","315.00",""
"KNEE 3 VIEWS","73562","CPT","70000131","CDM","320","RC","","Facility","Outpatient","","","397","317.60","397.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","206.44","52","","","Percent of Total Billed Charges","neg_dollar:$206.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","397.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","206.44","52","","","Percent of Total Billed Charges","neg_dollar:$206.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","206.44","52","","","Percent of Total Billed Charges","neg_dollar:$206.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","206.44","52","","","Percent of Total Billed Charges","neg_dollar:$206.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","341.42","86","","","Percent of Total Billed Charges","neg_dollar:$341.42","277.90","70","","","Percent of Total Billed Charges","neg_dollar:$277.90","206.44","52","","","Percent of Total Billed Charges","neg_dollar:$206.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","233.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$233.23;102% of Medicaid interim rate","297.75","75","","","Percent of Total Billed Charges","neg_dollar:$297.75","341.42","86","","","Percent of Total Billed Charges","neg_dollar:$341.42","277.90","70","","","Percent of Total Billed Charges","neg_dollar:$277.90","226.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$226.29;103.5% of Medicaid interim rate","397.00","150","","","Percent of Total Billed Charges","neg_dollar:$613.78;150% of Medicaid interim rate","317.60","80","","","Percent of Total Billed Charges","neg_dollar:$317.60;Percent of Total Billed Charges","","","","279.00","Fee Schedule","","206.44","52","","","Percent of Total Billed Charges","neg_dollar:$206.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","206.44","52","","","Percent of Total Billed Charges","neg_dollar:$206.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","206.00","397.00",""
"KNEE MIN 4 VIEWS","73564","CPT","70000132","CDM","320","RC","","Facility","Outpatient","","","515","412.00","515.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","267.80","52","","","Percent of Total Billed Charges","neg_dollar:$267.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","515.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","267.80","52","","","Percent of Total Billed Charges","neg_dollar:$267.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","267.80","52","","","Percent of Total Billed Charges","neg_dollar:$267.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","267.80","52","","","Percent of Total Billed Charges","neg_dollar:$267.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","442.90","86","","","Percent of Total Billed Charges","neg_dollar:$442.90","360.50","70","","","Percent of Total Billed Charges","neg_dollar:$360.50","267.80","52","","","Percent of Total Billed Charges","neg_dollar:$267.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","302.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$302.56;102% of Medicaid interim rate","386.25","75","","","Percent of Total Billed Charges","neg_dollar:$386.25","442.90","86","","","Percent of Total Billed Charges","neg_dollar:$442.90","360.50","70","","","Percent of Total Billed Charges","neg_dollar:$360.50","293.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$293.54;103.5% of Medicaid interim rate","515.00","150","","","Percent of Total Billed Charges","neg_dollar:$796.21;150% of Medicaid interim rate","412.00","80","","","Percent of Total Billed Charges","neg_dollar:$412;Percent of Total Billed Charges","","","","515.00","Fee Schedule","","267.80","52","","","Percent of Total Billed Charges","neg_dollar:$267.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","267.80","52","","","Percent of Total Billed Charges","neg_dollar:$267.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","267.00","515.00",""
"KNEES STANDING AP","73565","CPT","70000340","CDM","320","RC","","Facility","Outpatient","","","299","239.20","299.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","299.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","257.14","86","","","Percent of Total Billed Charges","neg_dollar:$257.14","209.29","70","","","Percent of Total Billed Charges","neg_dollar:$209.29","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","175.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$175.66;102% of Medicaid interim rate","224.25","75","","","Percent of Total Billed Charges","neg_dollar:$224.25","257.14","86","","","Percent of Total Billed Charges","neg_dollar:$257.14","209.29","70","","","Percent of Total Billed Charges","neg_dollar:$209.29","170.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$170.42;103.5% of Medicaid interim rate","299.00","150","","","Percent of Total Billed Charges","neg_dollar:$462.26;150% of Medicaid interim rate","239.20","80","","","Percent of Total Billed Charges","neg_dollar:$239.20;Percent of Total Billed Charges","","","","299.00","Fee Schedule","","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","155.00","299.00",""
"TIBIA FIBULA 2 VIEWS","73590","CPT","70000134","CDM","320","RC","","Facility","Outpatient","","","289","231.20","289.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","150.28","52","","","Percent of Total Billed Charges","neg_dollar:$150.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","289.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","150.28","52","","","Percent of Total Billed Charges","neg_dollar:$150.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","150.28","52","","","Percent of Total Billed Charges","neg_dollar:$150.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","150.28","52","","","Percent of Total Billed Charges","neg_dollar:$150.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","248.54","86","","","Percent of Total Billed Charges","neg_dollar:$248.54","202.29","70","","","Percent of Total Billed Charges","neg_dollar:$202.29","150.28","52","","","Percent of Total Billed Charges","neg_dollar:$150.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","169.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$169.78;102% of Medicaid interim rate","216.75","75","","","Percent of Total Billed Charges","neg_dollar:$216.75","248.54","86","","","Percent of Total Billed Charges","neg_dollar:$248.54","202.29","70","","","Percent of Total Billed Charges","neg_dollar:$202.29","164.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$164.73;103.5% of Medicaid interim rate","289.00","150","","","Percent of Total Billed Charges","neg_dollar:$446.80;150% of Medicaid interim rate","231.20","80","","","Percent of Total Billed Charges","neg_dollar:$231.20;Percent of Total Billed Charges","","","","289.00","Fee Schedule","","150.28","52","","","Percent of Total Billed Charges","neg_dollar:$150.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","150.28","52","","","Percent of Total Billed Charges","neg_dollar:$150.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","150.00","289.00",""
"LOWR EXTR INFANT MIN 2 VIEWS","73592","CPT","70000135","CDM","320","RC","","Facility","Outpatient","","","356","284.80","356.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","185.12","52","","","Percent of Total Billed Charges","neg_dollar:$185.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","356.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","185.12","52","","","Percent of Total Billed Charges","neg_dollar:$185.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","185.12","52","","","Percent of Total Billed Charges","neg_dollar:$185.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","185.12","52","","","Percent of Total Billed Charges","neg_dollar:$185.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","306.15","86","","","Percent of Total Billed Charges","neg_dollar:$306.15","249.20","70","","","Percent of Total Billed Charges","neg_dollar:$249.20","185.12","52","","","Percent of Total Billed Charges","neg_dollar:$185.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","209.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$209.14;102% of Medicaid interim rate","267.00","75","","","Percent of Total Billed Charges","neg_dollar:$267","306.15","86","","","Percent of Total Billed Charges","neg_dollar:$306.15","249.20","70","","","Percent of Total Billed Charges","neg_dollar:$249.20","202.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$202.92;103.5% of Medicaid interim rate","356.00","150","","","Percent of Total Billed Charges","neg_dollar:$550.39;150% of Medicaid interim rate","284.80","80","","","Percent of Total Billed Charges","neg_dollar:$284.80;Percent of Total Billed Charges","","","","356.00","Fee Schedule","","185.12","52","","","Percent of Total Billed Charges","neg_dollar:$185.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","185.12","52","","","Percent of Total Billed Charges","neg_dollar:$185.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","185.00","356.00",""
"ANKLE 2 VIEWS","73600","CPT","70000136","CDM","320","RC","","Facility","Outpatient","","","214","171.20","214.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","214.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.04","86","","","Percent of Total Billed Charges","neg_dollar:$184.04","149.79","70","","","Percent of Total Billed Charges","neg_dollar:$149.79","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","125.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$125.72;102% of Medicaid interim rate","160.50","75","","","Percent of Total Billed Charges","neg_dollar:$160.50","184.04","86","","","Percent of Total Billed Charges","neg_dollar:$184.04","149.79","70","","","Percent of Total Billed Charges","neg_dollar:$149.79","121.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$121.97;103.5% of Medicaid interim rate","214.00","150","","","Percent of Total Billed Charges","neg_dollar:$330.85;150% of Medicaid interim rate","171.20","80","","","Percent of Total Billed Charges","neg_dollar:$171.20;Percent of Total Billed Charges","","","","214.00","Fee Schedule","","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","111.00","214.00",""
"ANKLE MIN 3 VIEWS","73610","CPT","70000137","CDM","320","RC","","Facility","Outpatient","","","345","276.00","345.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","179.40","52","","","Percent of Total Billed Charges","neg_dollar:$179.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","345.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","179.40","52","","","Percent of Total Billed Charges","neg_dollar:$179.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","179.40","52","","","Percent of Total Billed Charges","neg_dollar:$179.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","179.40","52","","","Percent of Total Billed Charges","neg_dollar:$179.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","296.70","86","","","Percent of Total Billed Charges","neg_dollar:$296.70","241.49","70","","","Percent of Total Billed Charges","neg_dollar:$241.49","179.40","52","","","Percent of Total Billed Charges","neg_dollar:$179.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","202.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$202.68;102% of Medicaid interim rate","258.75","75","","","Percent of Total Billed Charges","neg_dollar:$258.75","296.70","86","","","Percent of Total Billed Charges","neg_dollar:$296.70","241.49","70","","","Percent of Total Billed Charges","neg_dollar:$241.49","196.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$196.64;103.5% of Medicaid interim rate","345.00","150","","","Percent of Total Billed Charges","neg_dollar:$533.38;150% of Medicaid interim rate","276.00","80","","","Percent of Total Billed Charges","neg_dollar:$276;Percent of Total Billed Charges","","","","243.00","Fee Schedule","","179.40","52","","","Percent of Total Billed Charges","neg_dollar:$179.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","179.40","52","","","Percent of Total Billed Charges","neg_dollar:$179.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","179.00","345.00",""
"FOOT 2 VIEWS","73620","CPT","70000138","CDM","320","RC","","Facility","Outpatient","","","214","171.20","214.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","214.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.04","86","","","Percent of Total Billed Charges","neg_dollar:$184.04","149.79","70","","","Percent of Total Billed Charges","neg_dollar:$149.79","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","125.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$125.72;102% of Medicaid interim rate","160.50","75","","","Percent of Total Billed Charges","neg_dollar:$160.50","184.04","86","","","Percent of Total Billed Charges","neg_dollar:$184.04","149.79","70","","","Percent of Total Billed Charges","neg_dollar:$149.79","121.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$121.97;103.5% of Medicaid interim rate","214.00","150","","","Percent of Total Billed Charges","neg_dollar:$330.85;150% of Medicaid interim rate","171.20","80","","","Percent of Total Billed Charges","neg_dollar:$171.20;Percent of Total Billed Charges","","","","214.00","Fee Schedule","","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","111.00","214.00",""
"FOOT MIN 3 VIEWS","73630","CPT","70000139","CDM","320","RC","","Facility","Outpatient","","","299","239.20","299.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","299.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","257.14","86","","","Percent of Total Billed Charges","neg_dollar:$257.14","209.29","70","","","Percent of Total Billed Charges","neg_dollar:$209.29","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","175.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$175.66;102% of Medicaid interim rate","224.25","75","","","Percent of Total Billed Charges","neg_dollar:$224.25","257.14","86","","","Percent of Total Billed Charges","neg_dollar:$257.14","209.29","70","","","Percent of Total Billed Charges","neg_dollar:$209.29","170.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$170.42;103.5% of Medicaid interim rate","299.00","150","","","Percent of Total Billed Charges","neg_dollar:$462.26;150% of Medicaid interim rate","239.20","80","","","Percent of Total Billed Charges","neg_dollar:$239.20;Percent of Total Billed Charges","","","","299.00","Fee Schedule","","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","155.48","52","","","Percent of Total Billed Charges","neg_dollar:$155.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","155.00","299.00",""
"CALCANEUS MIN 2 VIEWS","73650","CPT","70000140","CDM","320","RC","","Facility","Outpatient","","","274","219.20","274.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","274.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","235.64","86","","","Percent of Total Billed Charges","neg_dollar:$235.64","191.79","70","","","Percent of Total Billed Charges","neg_dollar:$191.79","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","160.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$160.97;102% of Medicaid interim rate","205.50","75","","","Percent of Total Billed Charges","neg_dollar:$205.50","235.64","86","","","Percent of Total Billed Charges","neg_dollar:$235.64","191.79","70","","","Percent of Total Billed Charges","neg_dollar:$191.79","156.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$156.17;103.5% of Medicaid interim rate","274.00","150","","","Percent of Total Billed Charges","neg_dollar:$423.61;150% of Medicaid interim rate","219.20","80","","","Percent of Total Billed Charges","neg_dollar:$219.20;Percent of Total Billed Charges","","","","274.00","Fee Schedule","","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","142.48","52","","","Percent of Total Billed Charges","neg_dollar:$142.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","142.00","274.00",""
"TOE OR TOES MIN 2 VIEWS","73660","CPT","70000141","CDM","320","RC","","Facility","Outpatient","","","313","250.40","313.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","313.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","269.18","86","","","Percent of Total Billed Charges","neg_dollar:$269.18","219.10","70","","","Percent of Total Billed Charges","neg_dollar:$219.10","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","183.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$183.88;102% of Medicaid interim rate","234.75","75","","","Percent of Total Billed Charges","neg_dollar:$234.75","269.18","86","","","Percent of Total Billed Charges","neg_dollar:$269.18","219.10","70","","","Percent of Total Billed Charges","neg_dollar:$219.10","178.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$178.41;103.5% of Medicaid interim rate","313.00","150","","","Percent of Total Billed Charges","neg_dollar:$483.91;150% of Medicaid interim rate","250.40","80","","","Percent of Total Billed Charges","neg_dollar:$250.40;Percent of Total Billed Charges","","","","313.00","Fee Schedule","","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.00","313.00",""
"CT LOWER EXTR WO CONTRAST","73700","CPT","70000142","CDM","352","RC","","Facility","Outpatient","","","2394","1915.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1244.88","52","","","Percent of Total Billed Charges","neg_dollar:$1244.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1244.88","52","","","Percent of Total Billed Charges","neg_dollar:$1244.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1244.88","52","","","Percent of Total Billed Charges","neg_dollar:$1244.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1244.88","52","","","Percent of Total Billed Charges","neg_dollar:$1244.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2058.84","86","","","Percent of Total Billed Charges","neg_dollar:$2058.84","1675.80","70","","","Percent of Total Billed Charges","neg_dollar:$1675.80","1244.88","52","","","Percent of Total Billed Charges","neg_dollar:$1244.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","1406.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$1406.47;102% of Medicaid interim rate","1795.50","75","","","Percent of Total Billed Charges","neg_dollar:$1795.50","2058.84","86","","","Percent of Total Billed Charges","neg_dollar:$2058.84","1675.80","70","","","Percent of Total Billed Charges","neg_dollar:$1675.80","1364.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$1364.58;103.5% of Medicaid interim rate","2394.00","150","","","Percent of Total Billed Charges","neg_dollar:$3701.24;150% of Medicaid interim rate","1915.20","80","","","Percent of Total Billed Charges","neg_dollar:$1915.20;Percent of Total Billed Charges","","","","2394.00","Fee Schedule","","1244.88","52","","","Percent of Total Billed Charges","neg_dollar:$1244.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1244.88","52","","","Percent of Total Billed Charges","neg_dollar:$1244.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2394.00",""
"CT LOWER EXTR W CONTRAST","73701","CPT","70000143","CDM","352","RC","","Facility","Outpatient","","","2857","2285.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1485.64","52","","","Percent of Total Billed Charges","neg_dollar:$1485.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1485.64","52","","","Percent of Total Billed Charges","neg_dollar:$1485.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1485.64","52","","","Percent of Total Billed Charges","neg_dollar:$1485.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1485.64","52","","","Percent of Total Billed Charges","neg_dollar:$1485.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2457.02","86","","","Percent of Total Billed Charges","neg_dollar:$2457.02","1999.89","70","","","Percent of Total Billed Charges","neg_dollar:$1999.89","1485.64","52","","","Percent of Total Billed Charges","neg_dollar:$1485.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","1678.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1678.48;102% of Medicaid interim rate","2142.75","75","","","Percent of Total Billed Charges","neg_dollar:$2142.75","2457.02","86","","","Percent of Total Billed Charges","neg_dollar:$2457.02","1999.89","70","","","Percent of Total Billed Charges","neg_dollar:$1999.89","1628.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1628.48;103.5% of Medicaid interim rate","2857.00","150","","","Percent of Total Billed Charges","neg_dollar:$4417.06;150% of Medicaid interim rate","2285.60","80","","","Percent of Total Billed Charges","neg_dollar:$2285.60;Percent of Total Billed Charges","","","","2857.00","Fee Schedule","","1485.64","52","","","Percent of Total Billed Charges","neg_dollar:$1485.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","1485.64","52","","","Percent of Total Billed Charges","neg_dollar:$1485.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2857.00",""
"CT LOWER EXTR W WO CONTRAST","73702","CPT","70000341","CDM","352","RC","","Facility","Outpatient","","","3320","2656.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1726.40","52","","","Percent of Total Billed Charges","neg_dollar:$1726.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1726.40","52","","","Percent of Total Billed Charges","neg_dollar:$1726.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1726.40","52","","","Percent of Total Billed Charges","neg_dollar:$1726.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1726.40","52","","","Percent of Total Billed Charges","neg_dollar:$1726.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2855.20","86","","","Percent of Total Billed Charges","neg_dollar:$2855.20","2324.00","70","","","Percent of Total Billed Charges","neg_dollar:$2324","1726.40","52","","","Percent of Total Billed Charges","neg_dollar:$1726.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","1950.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$1950.49;102% of Medicaid interim rate","2490.00","75","","","Percent of Total Billed Charges","neg_dollar:$2490","2855.20","86","","","Percent of Total Billed Charges","neg_dollar:$2855.20","2324.00","70","","","Percent of Total Billed Charges","neg_dollar:$2324","1892.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$1892.39;103.5% of Medicaid interim rate","3320.00","150","","","Percent of Total Billed Charges","neg_dollar:$5132.88;150% of Medicaid interim rate","2656.00","80","","","Percent of Total Billed Charges","neg_dollar:$2656;Percent of Total Billed Charges","","","","3320.00","Fee Schedule","","1726.40","52","","","Percent of Total Billed Charges","neg_dollar:$1726.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1726.40","52","","","Percent of Total Billed Charges","neg_dollar:$1726.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3320.00",""
"CT ANGIOGRAPHY LOWER EXTR W WO CONTRAST","73706","CPT","70000144","CDM","352","RC","","Facility","Outpatient","","","3190","2552.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2743.40","86","","","Percent of Total Billed Charges","neg_dollar:$2743.40","2233.00","70","","","Percent of Total Billed Charges","neg_dollar:$2233","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","1874.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$1874.12;102% of Medicaid interim rate","2392.50","75","","","Percent of Total Billed Charges","neg_dollar:$2392.50","2743.40","86","","","Percent of Total Billed Charges","neg_dollar:$2743.40","2233.00","70","","","Percent of Total Billed Charges","neg_dollar:$2233","1818.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$1818.30;103.5% of Medicaid interim rate","3190.00","150","","","Percent of Total Billed Charges","neg_dollar:$4931.89;150% of Medicaid interim rate","2552.00","80","","","Percent of Total Billed Charges","neg_dollar:$2552;Percent of Total Billed Charges","","","","3190.00","Fee Schedule","","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3190.00",""
"MRI LOW EXTR NOT JOINT WO CONTRAST","73718","CPT","70000145","CDM","610","RC","","Facility","Outpatient","","","3235","2588.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1682.20","52","","","Percent of Total Billed Charges","neg_dollar:$1682.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1682.20","52","","","Percent of Total Billed Charges","neg_dollar:$1682.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","1682.20","52","","","Percent of Total Billed Charges","neg_dollar:$1682.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","1682.20","52","","","Percent of Total Billed Charges","neg_dollar:$1682.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","2782.10","86","","","Percent of Total Billed Charges","neg_dollar:$2782.10","2264.50","70","","","Percent of Total Billed Charges","neg_dollar:$2264.50","1682.20","52","","","Percent of Total Billed Charges","neg_dollar:$1682.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","1900.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$1900.55;102% of Medicaid interim rate","2426.25","75","","","Percent of Total Billed Charges","neg_dollar:$2426.25","2782.10","86","","","Percent of Total Billed Charges","neg_dollar:$2782.10","2264.50","70","","","Percent of Total Billed Charges","neg_dollar:$2264.50","1843.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$1843.94;103.5% of Medicaid interim rate","3235.00","150","","","Percent of Total Billed Charges","neg_dollar:$5001.47;150% of Medicaid interim rate","2588.00","80","","","Percent of Total Billed Charges","neg_dollar:$2588;Percent of Total Billed Charges","","","","3235.00","Fee Schedule","","1682.20","52","","","Percent of Total Billed Charges","neg_dollar:$1682.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","1682.20","52","","","Percent of Total Billed Charges","neg_dollar:$1682.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3235.00",""
"MRI LOW EXTR NOT JOINT W CONTRAST","73719","CPT","70000146","CDM","610","RC","","Facility","Outpatient","","","3698","2958.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1922.96","52","","","Percent of Total Billed Charges","neg_dollar:$1922.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1922.96","52","","","Percent of Total Billed Charges","neg_dollar:$1922.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1922.96","52","","","Percent of Total Billed Charges","neg_dollar:$1922.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1922.96","52","","","Percent of Total Billed Charges","neg_dollar:$1922.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","3180.27","86","","","Percent of Total Billed Charges","neg_dollar:$3180.27","2588.60","70","","","Percent of Total Billed Charges","neg_dollar:$2588.60","1922.96","52","","","Percent of Total Billed Charges","neg_dollar:$1922.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","2172.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$2172.57;102% of Medicaid interim rate","2773.50","75","","","Percent of Total Billed Charges","neg_dollar:$2773.50","3180.27","86","","","Percent of Total Billed Charges","neg_dollar:$3180.27","2588.60","70","","","Percent of Total Billed Charges","neg_dollar:$2588.60","2107.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$2107.85;103.5% of Medicaid interim rate","3698.00","150","","","Percent of Total Billed Charges","neg_dollar:$5717.29;150% of Medicaid interim rate","2958.40","80","","","Percent of Total Billed Charges","neg_dollar:$2958.40;Percent of Total Billed Charges","","","","3698.00","Fee Schedule","","1922.96","52","","","Percent of Total Billed Charges","neg_dollar:$1922.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","1922.96","52","","","Percent of Total Billed Charges","neg_dollar:$1922.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3698.00",""
"MRI LOW EXTR NOT JOINT W WO CONTR","73720","CPT","70000147","CDM","610","RC","","Facility","Outpatient","","","5109","4087.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","4393.74","86","","","Percent of Total Billed Charges","neg_dollar:$4393.74","3576.29","70","","","Percent of Total Billed Charges","neg_dollar:$3576.29","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","3001.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$3001.53;102% of Medicaid interim rate","3831.75","75","","","Percent of Total Billed Charges","neg_dollar:$3831.75","4393.74","86","","","Percent of Total Billed Charges","neg_dollar:$4393.74","3576.29","70","","","Percent of Total Billed Charges","neg_dollar:$3576.29","2912.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$2912.12;103.5% of Medicaid interim rate","5109.00","150","","","Percent of Total Billed Charges","neg_dollar:$7898.76;150% of Medicaid interim rate","4087.20","80","","","Percent of Total Billed Charges","neg_dollar:$4087.20;Percent of Total Billed Charges","","","","5109.00","Fee Schedule","","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","2656.68","52","","","Percent of Total Billed Charges","neg_dollar:$2656.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5109.00",""
"MRI LOW EXTR ANY JOINT WO CONTRAST","73721","CPT","70000148","CDM","610","RC","","Facility","Outpatient","","","3325","2660.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1729.00","52","","","Percent of Total Billed Charges","neg_dollar:$1729;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1729.00","52","","","Percent of Total Billed Charges","neg_dollar:$1729;102% Medicare Outpatient Cost to Charge Ratio of 52%","1729.00","52","","","Percent of Total Billed Charges","neg_dollar:$1729;102% Medicare Outpatient Cost to Charge Ratio of 52%","1729.00","52","","","Percent of Total Billed Charges","neg_dollar:$1729;102% Medicare Outpatient Cost to Charge Ratio of 52%","2859.50","86","","","Percent of Total Billed Charges","neg_dollar:$2859.50","2327.50","70","","","Percent of Total Billed Charges","neg_dollar:$2327.50","1729.00","52","","","Percent of Total Billed Charges","neg_dollar:$1729;105% Medicare Outpatient Cost to Charge Ratio of 52%","1953.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$1953.43;102% of Medicaid interim rate","2493.75","75","","","Percent of Total Billed Charges","neg_dollar:$2493.75","2859.50","86","","","Percent of Total Billed Charges","neg_dollar:$2859.50","2327.50","70","","","Percent of Total Billed Charges","neg_dollar:$2327.50","1895.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$1895.24;103.5% of Medicaid interim rate","3325.00","150","","","Percent of Total Billed Charges","neg_dollar:$5140.61;150% of Medicaid interim rate","2660.00","80","","","Percent of Total Billed Charges","neg_dollar:$2660;Percent of Total Billed Charges","","","","3325.00","Fee Schedule","","1729.00","52","","","Percent of Total Billed Charges","neg_dollar:$1729;100% Medicare Outpatient Cost to Charge Ratio of 52%","1729.00","52","","","Percent of Total Billed Charges","neg_dollar:$1729;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3325.00",""
"MRI LOW EXTR ANY JOINT W CONTRAST","73722","CPT","70000149","CDM","610","RC","","Facility","Outpatient","","","3788","3030.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1969.76","52","","","Percent of Total Billed Charges","neg_dollar:$1969.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1969.76","52","","","Percent of Total Billed Charges","neg_dollar:$1969.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1969.76","52","","","Percent of Total Billed Charges","neg_dollar:$1969.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1969.76","52","","","Percent of Total Billed Charges","neg_dollar:$1969.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","3257.68","86","","","Percent of Total Billed Charges","neg_dollar:$3257.68","2651.60","70","","","Percent of Total Billed Charges","neg_dollar:$2651.60","1969.76","52","","","Percent of Total Billed Charges","neg_dollar:$1969.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","2225.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$2225.44;102% of Medicaid interim rate","2841.00","75","","","Percent of Total Billed Charges","neg_dollar:$2841","3257.68","86","","","Percent of Total Billed Charges","neg_dollar:$3257.68","2651.60","70","","","Percent of Total Billed Charges","neg_dollar:$2651.60","2159.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$2159.16;103.5% of Medicaid interim rate","3788.00","150","","","Percent of Total Billed Charges","neg_dollar:$5856.43;150% of Medicaid interim rate","3030.40","80","","","Percent of Total Billed Charges","neg_dollar:$3030.40;Percent of Total Billed Charges","","","","3788.00","Fee Schedule","","1969.76","52","","","Percent of Total Billed Charges","neg_dollar:$1969.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1969.76","52","","","Percent of Total Billed Charges","neg_dollar:$1969.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3788.00",""
"MRI LOW EXTR ANY JOINT W WO CONTR","73723","CPT","70000150","CDM","610","RC","","Facility","Outpatient","","","4989","3991.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2594.28","52","","","Percent of Total Billed Charges","neg_dollar:$2594.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2594.28","52","","","Percent of Total Billed Charges","neg_dollar:$2594.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","2594.28","52","","","Percent of Total Billed Charges","neg_dollar:$2594.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","2594.28","52","","","Percent of Total Billed Charges","neg_dollar:$2594.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","4290.54","86","","","Percent of Total Billed Charges","neg_dollar:$4290.54","3492.29","70","","","Percent of Total Billed Charges","neg_dollar:$3492.29","2594.28","52","","","Percent of Total Billed Charges","neg_dollar:$2594.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","2931.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$2931.03;102% of Medicaid interim rate","3741.75","75","","","Percent of Total Billed Charges","neg_dollar:$3741.75","4290.54","86","","","Percent of Total Billed Charges","neg_dollar:$4290.54","3492.29","70","","","Percent of Total Billed Charges","neg_dollar:$3492.29","2843.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$2843.72;103.5% of Medicaid interim rate","4989.00","150","","","Percent of Total Billed Charges","neg_dollar:$7713.24;150% of Medicaid interim rate","3991.20","80","","","Percent of Total Billed Charges","neg_dollar:$3991.20;Percent of Total Billed Charges","","","","4989.00","Fee Schedule","","2594.28","52","","","Percent of Total Billed Charges","neg_dollar:$2594.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","2594.28","52","","","Percent of Total Billed Charges","neg_dollar:$2594.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4989.00",""
"MRA LOW EXTR WO CONTRAST","73725","CPT","70000286","CDM","616","RC","","Facility","Outpatient","","","4013","3210.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2086.76","52","","","Percent of Total Billed Charges","neg_dollar:$2086.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2086.76","52","","","Percent of Total Billed Charges","neg_dollar:$2086.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2086.76","52","","","Percent of Total Billed Charges","neg_dollar:$2086.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2086.76","52","","","Percent of Total Billed Charges","neg_dollar:$2086.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","3451.18","86","","","Percent of Total Billed Charges","neg_dollar:$3451.18","2809.10","70","","","Percent of Total Billed Charges","neg_dollar:$2809.10","2086.76","52","","","Percent of Total Billed Charges","neg_dollar:$2086.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","2357.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$2357.63;102% of Medicaid interim rate","3009.75","75","","","Percent of Total Billed Charges","neg_dollar:$3009.75","3451.18","86","","","Percent of Total Billed Charges","neg_dollar:$3451.18","2809.10","70","","","Percent of Total Billed Charges","neg_dollar:$2809.10","2287.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$2287.41;103.5% of Medicaid interim rate","4013.00","150","","","Percent of Total Billed Charges","neg_dollar:$6204.29;150% of Medicaid interim rate","3210.40","80","","","Percent of Total Billed Charges","neg_dollar:$3210.40;Percent of Total Billed Charges","3691.96","92","","","Percent of Total Billed Charges","neg_dollar:$3691.96","2086.76","52","","","Percent of Total Billed Charges","neg_dollar:$2086.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","2086.76","52","","","Percent of Total Billed Charges","neg_dollar:$2086.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4013.00",""
"MRA LOW EXTR W WO CONTRAST","73725","CPT","70000287","CDM","616","RC","","Facility","Outpatient","","","4846","3876.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2519.92","52","","","Percent of Total Billed Charges","neg_dollar:$2519.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2519.92","52","","","Percent of Total Billed Charges","neg_dollar:$2519.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2519.92","52","","","Percent of Total Billed Charges","neg_dollar:$2519.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2519.92","52","","","Percent of Total Billed Charges","neg_dollar:$2519.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","4167.55","86","","","Percent of Total Billed Charges","neg_dollar:$4167.55","3392.20","70","","","Percent of Total Billed Charges","neg_dollar:$3392.20","2519.92","52","","","Percent of Total Billed Charges","neg_dollar:$2519.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","2847.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$2847.02;102% of Medicaid interim rate","3634.50","75","","","Percent of Total Billed Charges","neg_dollar:$3634.50","4167.55","86","","","Percent of Total Billed Charges","neg_dollar:$4167.55","3392.20","70","","","Percent of Total Billed Charges","neg_dollar:$3392.20","2762.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$2762.22;103.5% of Medicaid interim rate","4846.00","150","","","Percent of Total Billed Charges","neg_dollar:$7492.15;150% of Medicaid interim rate","3876.80","80","","","Percent of Total Billed Charges","neg_dollar:$3876.80;Percent of Total Billed Charges","4458.32","92","","","Percent of Total Billed Charges","neg_dollar:$4458.32","2519.92","52","","","Percent of Total Billed Charges","neg_dollar:$2519.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","2519.92","52","","","Percent of Total Billed Charges","neg_dollar:$2519.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4846.00",""
"MRA LOW EXTR W CONTRAST","73725","CPT","70000308","CDM","616","RC","","Facility","Outpatient","","","5038","4030.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2619.76","52","","","Percent of Total Billed Charges","neg_dollar:$2619.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2619.76","52","","","Percent of Total Billed Charges","neg_dollar:$2619.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2619.76","52","","","Percent of Total Billed Charges","neg_dollar:$2619.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2619.76","52","","","Percent of Total Billed Charges","neg_dollar:$2619.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","4332.68","86","","","Percent of Total Billed Charges","neg_dollar:$4332.68","3526.60","70","","","Percent of Total Billed Charges","neg_dollar:$3526.60","2619.76","52","","","Percent of Total Billed Charges","neg_dollar:$2619.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","2959.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$2959.81;102% of Medicaid interim rate","3778.50","75","","","Percent of Total Billed Charges","neg_dollar:$3778.50","4332.68","86","","","Percent of Total Billed Charges","neg_dollar:$4332.68","3526.60","70","","","Percent of Total Billed Charges","neg_dollar:$3526.60","2871.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$2871.66;103.5% of Medicaid interim rate","5038.00","150","","","Percent of Total Billed Charges","neg_dollar:$7788.99;150% of Medicaid interim rate","4030.40","80","","","Percent of Total Billed Charges","neg_dollar:$4030.40;Percent of Total Billed Charges","4634.96","92","","","Percent of Total Billed Charges","neg_dollar:$4634.96","2619.76","52","","","Percent of Total Billed Charges","neg_dollar:$2619.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","2619.76","52","","","Percent of Total Billed Charges","neg_dollar:$2619.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5038.00",""
"X-RAY EXAM ABDOMEN 1 VIEW","74018","CPT","70000804","CDM","320","RC","","Facility","Outpatient","","","423","338.40","423.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","423.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","363.78","86","","","Percent of Total Billed Charges","neg_dollar:$363.78","296.09","70","","","Percent of Total Billed Charges","neg_dollar:$296.09","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","248.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$248.51;102% of Medicaid interim rate","317.25","75","","","Percent of Total Billed Charges","neg_dollar:$317.25","363.78","86","","","Percent of Total Billed Charges","neg_dollar:$363.78","296.09","70","","","Percent of Total Billed Charges","neg_dollar:$296.09","241.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$241.10;103.5% of Medicaid interim rate","423.00","150","","","Percent of Total Billed Charges","neg_dollar:$653.97;150% of Medicaid interim rate","338.40","80","","","Percent of Total Billed Charges","neg_dollar:$338.40;Percent of Total Billed Charges","","","","335.00","Fee Schedule","","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","219.00","423.00",""
"X-RAY EXAM ABDOMEN 2 VIEWS","74019","CPT","70000805","CDM","320","RC","","Facility","Outpatient","","","478","382.40","478.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","248.56","52","","","Percent of Total Billed Charges","neg_dollar:$248.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","478.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","248.56","52","","","Percent of Total Billed Charges","neg_dollar:$248.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","248.56","52","","","Percent of Total Billed Charges","neg_dollar:$248.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","248.56","52","","","Percent of Total Billed Charges","neg_dollar:$248.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","411.08","86","","","Percent of Total Billed Charges","neg_dollar:$411.08","334.59","70","","","Percent of Total Billed Charges","neg_dollar:$334.59","248.56","52","","","Percent of Total Billed Charges","neg_dollar:$248.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","280.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$280.82;102% of Medicaid interim rate","358.50","75","","","Percent of Total Billed Charges","neg_dollar:$358.50","411.08","86","","","Percent of Total Billed Charges","neg_dollar:$411.08","334.59","70","","","Percent of Total Billed Charges","neg_dollar:$334.59","272.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$272.46;103.5% of Medicaid interim rate","478.00","150","","","Percent of Total Billed Charges","neg_dollar:$739.01;150% of Medicaid interim rate","382.40","80","","","Percent of Total Billed Charges","neg_dollar:$382.40;Percent of Total Billed Charges","","","","379.00","Fee Schedule","","248.56","52","","","Percent of Total Billed Charges","neg_dollar:$248.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","248.56","52","","","Percent of Total Billed Charges","neg_dollar:$248.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","248.00","478.00",""
"COMPL ACUTE ABDOMEN W 1 VW CHEST","74022","CPT","70000154","CDM","320","RC","","Facility","Outpatient","","","519","415.20","519.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","519.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","446.34","86","","","Percent of Total Billed Charges","neg_dollar:$446.34","363.29","70","","","Percent of Total Billed Charges","neg_dollar:$363.29","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","304.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$304.91;102% of Medicaid interim rate","389.25","75","","","Percent of Total Billed Charges","neg_dollar:$389.25","446.34","86","","","Percent of Total Billed Charges","neg_dollar:$446.34","363.29","70","","","Percent of Total Billed Charges","neg_dollar:$363.29","295.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$295.83;103.5% of Medicaid interim rate","519.00","150","","","Percent of Total Billed Charges","neg_dollar:$802.39;150% of Medicaid interim rate","415.20","80","","","Percent of Total Billed Charges","neg_dollar:$415.20;Percent of Total Billed Charges","","","","392.00","Fee Schedule","","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","269.88","52","","","Percent of Total Billed Charges","neg_dollar:$269.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","269.00","519.00",""
"CT ABDOMEN WO CONTRAST","74150","CPT","70000155","CDM","352","RC","","Facility","Outpatient","","","2261","1808.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1175.72","52","","","Percent of Total Billed Charges","neg_dollar:$1175.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1175.72","52","","","Percent of Total Billed Charges","neg_dollar:$1175.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1175.72","52","","","Percent of Total Billed Charges","neg_dollar:$1175.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1175.72","52","","","Percent of Total Billed Charges","neg_dollar:$1175.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1944.46","86","","","Percent of Total Billed Charges","neg_dollar:$1944.46","1582.69","70","","","Percent of Total Billed Charges","neg_dollar:$1582.69","1175.72","52","","","Percent of Total Billed Charges","neg_dollar:$1175.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","1328.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$1328.33;102% of Medicaid interim rate","1695.75","75","","","Percent of Total Billed Charges","neg_dollar:$1695.75","1944.46","86","","","Percent of Total Billed Charges","neg_dollar:$1944.46","1582.69","70","","","Percent of Total Billed Charges","neg_dollar:$1582.69","1288.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$1288.77;103.5% of Medicaid interim rate","2261.00","150","","","Percent of Total Billed Charges","neg_dollar:$3495.61;150% of Medicaid interim rate","1808.80","80","","","Percent of Total Billed Charges","neg_dollar:$1808.80;Percent of Total Billed Charges","","","","1796.00","Fee Schedule","","1175.72","52","","","Percent of Total Billed Charges","neg_dollar:$1175.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1175.72","52","","","Percent of Total Billed Charges","neg_dollar:$1175.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2261.00",""
"CT ABDOMEN W CONTRAST","74160","CPT","70000156","CDM","352","RC","","Facility","Outpatient","","","2894","2315.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1504.88","52","","","Percent of Total Billed Charges","neg_dollar:$1504.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1504.88","52","","","Percent of Total Billed Charges","neg_dollar:$1504.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1504.88","52","","","Percent of Total Billed Charges","neg_dollar:$1504.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1504.88","52","","","Percent of Total Billed Charges","neg_dollar:$1504.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2488.84","86","","","Percent of Total Billed Charges","neg_dollar:$2488.84","2025.80","70","","","Percent of Total Billed Charges","neg_dollar:$2025.80","1504.88","52","","","Percent of Total Billed Charges","neg_dollar:$1504.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","1700.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$1700.22;102% of Medicaid interim rate","2170.50","75","","","Percent of Total Billed Charges","neg_dollar:$2170.50","2488.84","86","","","Percent of Total Billed Charges","neg_dollar:$2488.84","2025.80","70","","","Percent of Total Billed Charges","neg_dollar:$2025.80","1649.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$1649.58;103.5% of Medicaid interim rate","2894.00","150","","","Percent of Total Billed Charges","neg_dollar:$4474.26;150% of Medicaid interim rate","2315.20","80","","","Percent of Total Billed Charges","neg_dollar:$2315.20;Percent of Total Billed Charges","","","","1937.00","Fee Schedule","","1504.88","52","","","Percent of Total Billed Charges","neg_dollar:$1504.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1504.88","52","","","Percent of Total Billed Charges","neg_dollar:$1504.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2894.00",""
"CT ABDOMEN W WO CONTRAST","74170","CPT","70000157","CDM","352","RC","","Facility","Outpatient","","","3357","2685.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1745.64","52","","","Percent of Total Billed Charges","neg_dollar:$1745.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1745.64","52","","","Percent of Total Billed Charges","neg_dollar:$1745.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1745.64","52","","","Percent of Total Billed Charges","neg_dollar:$1745.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1745.64","52","","","Percent of Total Billed Charges","neg_dollar:$1745.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2887.02","86","","","Percent of Total Billed Charges","neg_dollar:$2887.02","2349.89","70","","","Percent of Total Billed Charges","neg_dollar:$2349.89","1745.64","52","","","Percent of Total Billed Charges","neg_dollar:$1745.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","1972.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1972.23;102% of Medicaid interim rate","2517.75","75","","","Percent of Total Billed Charges","neg_dollar:$2517.75","2887.02","86","","","Percent of Total Billed Charges","neg_dollar:$2887.02","2349.89","70","","","Percent of Total Billed Charges","neg_dollar:$2349.89","1913.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1913.48;103.5% of Medicaid interim rate","3357.00","150","","","Percent of Total Billed Charges","neg_dollar:$5190.08;150% of Medicaid interim rate","2685.60","80","","","Percent of Total Billed Charges","neg_dollar:$2685.60;Percent of Total Billed Charges","","","","2360.00","Fee Schedule","","1745.64","52","","","Percent of Total Billed Charges","neg_dollar:$1745.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","1745.64","52","","","Percent of Total Billed Charges","neg_dollar:$1745.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3357.00",""
"CT ANGIO ABD AND PELV WO W CONTRAST","74174","CPT","70000600","CDM","352","RC","","Facility","Outpatient","","","4174","3339.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2170.48","52","","","Percent of Total Billed Charges","neg_dollar:$2170.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2170.48","52","","","Percent of Total Billed Charges","neg_dollar:$2170.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2170.48","52","","","Percent of Total Billed Charges","neg_dollar:$2170.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2170.48","52","","","Percent of Total Billed Charges","neg_dollar:$2170.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","3589.64","86","","","Percent of Total Billed Charges","neg_dollar:$3589.64","2921.79","70","","","Percent of Total Billed Charges","neg_dollar:$2921.79","2170.48","52","","","Percent of Total Billed Charges","neg_dollar:$2170.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","2452.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$2452.22;102% of Medicaid interim rate","3130.50","75","","","Percent of Total Billed Charges","neg_dollar:$3130.50","3589.64","86","","","Percent of Total Billed Charges","neg_dollar:$3589.64","2921.79","70","","","Percent of Total Billed Charges","neg_dollar:$2921.79","2379.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$2379.18;103.5% of Medicaid interim rate","4174.00","150","","","Percent of Total Billed Charges","neg_dollar:$6453.21;150% of Medicaid interim rate","3339.20","80","","","Percent of Total Billed Charges","neg_dollar:$3339.20;Percent of Total Billed Charges","","","","2082.00","Fee Schedule","","2170.48","52","","","Percent of Total Billed Charges","neg_dollar:$2170.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","2170.48","52","","","Percent of Total Billed Charges","neg_dollar:$2170.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4174.00",""
"CT ANGIOGRAPHY ABDOMEN W WO CONTRAST","74175","CPT","70000158","CDM","352","RC","","Facility","Outpatient","","","3190","2552.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2743.40","86","","","Percent of Total Billed Charges","neg_dollar:$2743.40","2233.00","70","","","Percent of Total Billed Charges","neg_dollar:$2233","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","1874.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$1874.12;102% of Medicaid interim rate","2392.50","75","","","Percent of Total Billed Charges","neg_dollar:$2392.50","2743.40","86","","","Percent of Total Billed Charges","neg_dollar:$2743.40","2233.00","70","","","Percent of Total Billed Charges","neg_dollar:$2233","1818.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$1818.30;103.5% of Medicaid interim rate","3190.00","150","","","Percent of Total Billed Charges","neg_dollar:$4931.89;150% of Medicaid interim rate","2552.00","80","","","Percent of Total Billed Charges","neg_dollar:$2552;Percent of Total Billed Charges","","","","2242.00","Fee Schedule","","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1658.80","52","","","Percent of Total Billed Charges","neg_dollar:$1658.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3190.00",""
"CT ABD & PELVIS WO CONTRAST","74176","CPT","70000281","CDM","352","RC","","Facility","Outpatient","","","4538","3630.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2359.76","52","","","Percent of Total Billed Charges","neg_dollar:$2359.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2359.76","52","","","Percent of Total Billed Charges","neg_dollar:$2359.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2359.76","52","","","Percent of Total Billed Charges","neg_dollar:$2359.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2359.76","52","","","Percent of Total Billed Charges","neg_dollar:$2359.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","3902.68","86","","","Percent of Total Billed Charges","neg_dollar:$3902.68","3176.60","70","","","Percent of Total Billed Charges","neg_dollar:$3176.60","2359.76","52","","","Percent of Total Billed Charges","neg_dollar:$2359.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","2666.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$2666.07;102% of Medicaid interim rate","3403.50","75","","","Percent of Total Billed Charges","neg_dollar:$3403.50","3902.68","86","","","Percent of Total Billed Charges","neg_dollar:$3902.68","3176.60","70","","","Percent of Total Billed Charges","neg_dollar:$3176.60","2586.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$2586.66;103.5% of Medicaid interim rate","4538.00","150","","","Percent of Total Billed Charges","neg_dollar:$7015.97;150% of Medicaid interim rate","3630.40","80","","","Percent of Total Billed Charges","neg_dollar:$3630.40;Percent of Total Billed Charges","","","","3606.00","Fee Schedule","","2359.76","52","","","Percent of Total Billed Charges","neg_dollar:$2359.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","2359.76","52","","","Percent of Total Billed Charges","neg_dollar:$2359.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4538.00",""
"CT ABDOMEN & PELVIS W CONTRAST","74177","CPT","70000282","CDM","352","RC","","Facility","Outpatient","","","5490","4392.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2854.80","52","","","Percent of Total Billed Charges","neg_dollar:$2854.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2854.80","52","","","Percent of Total Billed Charges","neg_dollar:$2854.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2854.80","52","","","Percent of Total Billed Charges","neg_dollar:$2854.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2854.80","52","","","Percent of Total Billed Charges","neg_dollar:$2854.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","4721.40","86","","","Percent of Total Billed Charges","neg_dollar:$4721.40","3842.99","70","","","Percent of Total Billed Charges","neg_dollar:$3842.99","2854.80","52","","","Percent of Total Billed Charges","neg_dollar:$2854.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","3225.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$3225.36;102% of Medicaid interim rate","4117.50","75","","","Percent of Total Billed Charges","neg_dollar:$4117.50","4721.40","86","","","Percent of Total Billed Charges","neg_dollar:$4721.40","3842.99","70","","","Percent of Total Billed Charges","neg_dollar:$3842.99","3129.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$3129.29;103.5% of Medicaid interim rate","5490.00","150","","","Percent of Total Billed Charges","neg_dollar:$8487.81;150% of Medicaid interim rate","4392.00","80","","","Percent of Total Billed Charges","neg_dollar:$4392;Percent of Total Billed Charges","","","","4472.00","Fee Schedule","","2854.80","52","","","Percent of Total Billed Charges","neg_dollar:$2854.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","2854.80","52","","","Percent of Total Billed Charges","neg_dollar:$2854.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5490.00",""
"CT ABD & PELVIS W WO CONTR 1+ REG/SEC","74178","CPT","70000283","CDM","352","RC","","Facility","Outpatient","","","5639","4511.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2932.28","52","","","Percent of Total Billed Charges","neg_dollar:$2932.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2932.28","52","","","Percent of Total Billed Charges","neg_dollar:$2932.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","2932.28","52","","","Percent of Total Billed Charges","neg_dollar:$2932.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","2932.28","52","","","Percent of Total Billed Charges","neg_dollar:$2932.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","4849.54","86","","","Percent of Total Billed Charges","neg_dollar:$4849.54","3947.29","70","","","Percent of Total Billed Charges","neg_dollar:$3947.29","2932.28","52","","","Percent of Total Billed Charges","neg_dollar:$2932.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","3312.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$3312.90;102% of Medicaid interim rate","4229.25","75","","","Percent of Total Billed Charges","neg_dollar:$4229.25","4849.54","86","","","Percent of Total Billed Charges","neg_dollar:$4849.54","3947.29","70","","","Percent of Total Billed Charges","neg_dollar:$3947.29","3214.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$3214.22;103.5% of Medicaid interim rate","5639.00","150","","","Percent of Total Billed Charges","neg_dollar:$8718.17;150% of Medicaid interim rate","4511.20","80","","","Percent of Total Billed Charges","neg_dollar:$4511.20;Percent of Total Billed Charges","","","","4705.00","Fee Schedule","","2932.28","52","","","Percent of Total Billed Charges","neg_dollar:$2932.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","2932.28","52","","","Percent of Total Billed Charges","neg_dollar:$2932.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5639.00",""
"MRI ABDOMEN WO CONTRAST","74181","CPT","70000159","CDM","610","RC","","Facility","Outpatient","","","3109","2487.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1616.68","52","","","Percent of Total Billed Charges","neg_dollar:$1616.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1616.68","52","","","Percent of Total Billed Charges","neg_dollar:$1616.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1616.68","52","","","Percent of Total Billed Charges","neg_dollar:$1616.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1616.68","52","","","Percent of Total Billed Charges","neg_dollar:$1616.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","2673.74","86","","","Percent of Total Billed Charges","neg_dollar:$2673.74","2176.29","70","","","Percent of Total Billed Charges","neg_dollar:$2176.29","1616.68","52","","","Percent of Total Billed Charges","neg_dollar:$1616.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","1826.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1826.53;102% of Medicaid interim rate","2331.75","75","","","Percent of Total Billed Charges","neg_dollar:$2331.75","2673.74","86","","","Percent of Total Billed Charges","neg_dollar:$2673.74","2176.29","70","","","Percent of Total Billed Charges","neg_dollar:$2176.29","1772.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$1772.12;103.5% of Medicaid interim rate","3109.00","150","","","Percent of Total Billed Charges","neg_dollar:$4806.66;150% of Medicaid interim rate","2487.20","80","","","Percent of Total Billed Charges","neg_dollar:$2487.20;Percent of Total Billed Charges","","","","3109.00","Fee Schedule","","1616.68","52","","","Percent of Total Billed Charges","neg_dollar:$1616.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","1616.68","52","","","Percent of Total Billed Charges","neg_dollar:$1616.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3109.00",""
"MRI ABDOMEN W CONTRAST","74182","CPT","70000160","CDM","610","RC","","Facility","Outpatient","","","3877","3101.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2016.04","52","","","Percent of Total Billed Charges","neg_dollar:$2016.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2016.04","52","","","Percent of Total Billed Charges","neg_dollar:$2016.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2016.04","52","","","Percent of Total Billed Charges","neg_dollar:$2016.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2016.04","52","","","Percent of Total Billed Charges","neg_dollar:$2016.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","3334.22","86","","","Percent of Total Billed Charges","neg_dollar:$3334.22","2713.89","70","","","Percent of Total Billed Charges","neg_dollar:$2713.89","2016.04","52","","","Percent of Total Billed Charges","neg_dollar:$2016.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","2277.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$2277.73;102% of Medicaid interim rate","2907.75","75","","","Percent of Total Billed Charges","neg_dollar:$2907.75","3334.22","86","","","Percent of Total Billed Charges","neg_dollar:$3334.22","2713.89","70","","","Percent of Total Billed Charges","neg_dollar:$2713.89","2209.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$2209.89;103.5% of Medicaid interim rate","3877.00","150","","","Percent of Total Billed Charges","neg_dollar:$5994.03;150% of Medicaid interim rate","3101.60","80","","","Percent of Total Billed Charges","neg_dollar:$3101.60;Percent of Total Billed Charges","","","","3877.00","Fee Schedule","","2016.04","52","","","Percent of Total Billed Charges","neg_dollar:$2016.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","2016.04","52","","","Percent of Total Billed Charges","neg_dollar:$2016.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3877.00",""
"MRI ABDOMEN W WO CONTRAST","74183","CPT","70000161","CDM","610","RC","","Facility","Outpatient","","","4340","3472.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2256.80","52","","","Percent of Total Billed Charges","neg_dollar:$2256.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2256.80","52","","","Percent of Total Billed Charges","neg_dollar:$2256.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2256.80","52","","","Percent of Total Billed Charges","neg_dollar:$2256.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2256.80","52","","","Percent of Total Billed Charges","neg_dollar:$2256.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","3732.40","86","","","Percent of Total Billed Charges","neg_dollar:$3732.40","3038.00","70","","","Percent of Total Billed Charges","neg_dollar:$3038","2256.80","52","","","Percent of Total Billed Charges","neg_dollar:$2256.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","2549.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$2549.74;102% of Medicaid interim rate","3255.00","75","","","Percent of Total Billed Charges","neg_dollar:$3255","3732.40","86","","","Percent of Total Billed Charges","neg_dollar:$3732.40","3038.00","70","","","Percent of Total Billed Charges","neg_dollar:$3038","2473.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$2473.79;103.5% of Medicaid interim rate","4340.00","150","","","Percent of Total Billed Charges","neg_dollar:$6709.85;150% of Medicaid interim rate","3472.00","80","","","Percent of Total Billed Charges","neg_dollar:$3472;Percent of Total Billed Charges","","","","3448.00","Fee Schedule","","2256.80","52","","","Percent of Total Billed Charges","neg_dollar:$2256.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","2256.80","52","","","Percent of Total Billed Charges","neg_dollar:$2256.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4340.00",""
"MRA ABDOMEN W CONTRAST","74185","CPT","70000304","CDM","610","RC","","Facility","Outpatient","","","4482","3585.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2330.64","52","","","Percent of Total Billed Charges","neg_dollar:$2330.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2330.64","52","","","Percent of Total Billed Charges","neg_dollar:$2330.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2330.64","52","","","Percent of Total Billed Charges","neg_dollar:$2330.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2330.64","52","","","Percent of Total Billed Charges","neg_dollar:$2330.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","3854.52","86","","","Percent of Total Billed Charges","neg_dollar:$3854.52","3137.39","70","","","Percent of Total Billed Charges","neg_dollar:$3137.39","2330.64","52","","","Percent of Total Billed Charges","neg_dollar:$2330.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","2633.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$2633.17;102% of Medicaid interim rate","3361.50","75","","","Percent of Total Billed Charges","neg_dollar:$3361.50","3854.52","86","","","Percent of Total Billed Charges","neg_dollar:$3854.52","3137.39","70","","","Percent of Total Billed Charges","neg_dollar:$3137.39","2554.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$2554.74;103.5% of Medicaid interim rate","4482.00","150","","","Percent of Total Billed Charges","neg_dollar:$6929.39;150% of Medicaid interim rate","3585.60","80","","","Percent of Total Billed Charges","neg_dollar:$3585.60;Percent of Total Billed Charges","","","","4482.00","Fee Schedule","","2330.64","52","","","Percent of Total Billed Charges","neg_dollar:$2330.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","2330.64","52","","","Percent of Total Billed Charges","neg_dollar:$2330.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4482.00",""
"MRA ABDOMEN WO CONTRAST","74185","CPT","70000305","CDM","610","RC","","Facility","Outpatient","","","2836","2268.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1474.72","52","","","Percent of Total Billed Charges","neg_dollar:$1474.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1474.72","52","","","Percent of Total Billed Charges","neg_dollar:$1474.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1474.72","52","","","Percent of Total Billed Charges","neg_dollar:$1474.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1474.72","52","","","Percent of Total Billed Charges","neg_dollar:$1474.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","2438.96","86","","","Percent of Total Billed Charges","neg_dollar:$2438.96","1985.19","70","","","Percent of Total Billed Charges","neg_dollar:$1985.19","1474.72","52","","","Percent of Total Billed Charges","neg_dollar:$1474.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","1666.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1666.14;102% of Medicaid interim rate","2127.00","75","","","Percent of Total Billed Charges","neg_dollar:$2127","2438.96","86","","","Percent of Total Billed Charges","neg_dollar:$2438.96","1985.19","70","","","Percent of Total Billed Charges","neg_dollar:$1985.19","1616.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$1616.51;103.5% of Medicaid interim rate","2836.00","150","","","Percent of Total Billed Charges","neg_dollar:$4384.59;150% of Medicaid interim rate","2268.80","80","","","Percent of Total Billed Charges","neg_dollar:$2268.80;Percent of Total Billed Charges","","","","2836.00","Fee Schedule","","1474.72","52","","","Percent of Total Billed Charges","neg_dollar:$1474.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1474.72","52","","","Percent of Total Billed Charges","neg_dollar:$1474.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2836.00",""
"MRA ABDOMEN W WO CONTRAST","74185","CPT","70000306","CDM","610","RC","","Facility","Outpatient","","","4946","3956.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2571.92","52","","","Percent of Total Billed Charges","neg_dollar:$2571.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2571.92","52","","","Percent of Total Billed Charges","neg_dollar:$2571.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2571.92","52","","","Percent of Total Billed Charges","neg_dollar:$2571.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2571.92","52","","","Percent of Total Billed Charges","neg_dollar:$2571.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","4253.55","86","","","Percent of Total Billed Charges","neg_dollar:$4253.55","3462.20","70","","","Percent of Total Billed Charges","neg_dollar:$3462.20","2571.92","52","","","Percent of Total Billed Charges","neg_dollar:$2571.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","2905.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$2905.77;102% of Medicaid interim rate","3709.50","75","","","Percent of Total Billed Charges","neg_dollar:$3709.50","4253.55","86","","","Percent of Total Billed Charges","neg_dollar:$4253.55","3462.20","70","","","Percent of Total Billed Charges","neg_dollar:$3462.20","2819.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$2819.22;103.5% of Medicaid interim rate","4946.00","150","","","Percent of Total Billed Charges","neg_dollar:$7646.76;150% of Medicaid interim rate","3956.80","80","","","Percent of Total Billed Charges","neg_dollar:$3956.80;Percent of Total Billed Charges","","","","4946.00","Fee Schedule","","2571.92","52","","","Percent of Total Billed Charges","neg_dollar:$2571.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","2571.92","52","","","Percent of Total Billed Charges","neg_dollar:$2571.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4946.00",""
"SWALLOWING FUNCTION W CINE VIDEO","74230","CPT","70000163","CDM","320","RC","","Facility","Outpatient","","","382","305.60","382.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","198.64","52","","","Percent of Total Billed Charges","neg_dollar:$198.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","382.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","198.64","52","","","Percent of Total Billed Charges","neg_dollar:$198.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","198.64","52","","","Percent of Total Billed Charges","neg_dollar:$198.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","198.64","52","","","Percent of Total Billed Charges","neg_dollar:$198.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","328.52","86","","","Percent of Total Billed Charges","neg_dollar:$328.52","267.40","70","","","Percent of Total Billed Charges","neg_dollar:$267.40","198.64","52","","","Percent of Total Billed Charges","neg_dollar:$198.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","224.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$224.42;102% of Medicaid interim rate","286.50","75","","","Percent of Total Billed Charges","neg_dollar:$286.50","328.52","86","","","Percent of Total Billed Charges","neg_dollar:$328.52","267.40","70","","","Percent of Total Billed Charges","neg_dollar:$267.40","217.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$217.73;103.5% of Medicaid interim rate","382.00","150","","","Percent of Total Billed Charges","neg_dollar:$590.59;150% of Medicaid interim rate","305.60","80","","","Percent of Total Billed Charges","neg_dollar:$305.60;Percent of Total Billed Charges","","","","249.00","Fee Schedule","","198.64","52","","","Percent of Total Billed Charges","neg_dollar:$198.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","198.64","52","","","Percent of Total Billed Charges","neg_dollar:$198.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","198.00","382.00",""
"CHOLANGIOGRAM INTRAOP","74300","CPT","70000171","CDM","320","RC","","Facility","Outpatient","","","1400","1120.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","728.00","52","","","Percent of Total Billed Charges","neg_dollar:$728;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","728.00","52","","","Percent of Total Billed Charges","neg_dollar:$728;102% Medicare Outpatient Cost to Charge Ratio of 52%","728.00","52","","","Percent of Total Billed Charges","neg_dollar:$728;102% Medicare Outpatient Cost to Charge Ratio of 52%","728.00","52","","","Percent of Total Billed Charges","neg_dollar:$728;102% Medicare Outpatient Cost to Charge Ratio of 52%","1204.00","86","","","Percent of Total Billed Charges","neg_dollar:$1204","979.99","70","","","Percent of Total Billed Charges","neg_dollar:$979.99","728.00","52","","","Percent of Total Billed Charges","neg_dollar:$728;105% Medicare Outpatient Cost to Charge Ratio of 52%","822.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$822.49;102% of Medicaid interim rate","1050.00","75","","","Percent of Total Billed Charges","neg_dollar:$1050","1204.00","86","","","Percent of Total Billed Charges","neg_dollar:$1204","979.99","70","","","Percent of Total Billed Charges","neg_dollar:$979.99","797.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$797.99;103.5% of Medicaid interim rate","1400.00","150","","","Percent of Total Billed Charges","neg_dollar:$2164.47;150% of Medicaid interim rate","1120.00","80","","","Percent of Total Billed Charges","neg_dollar:$1120;Percent of Total Billed Charges","","","","1400.00","Fee Schedule","","728.00","52","","","Percent of Total Billed Charges","neg_dollar:$728;100% Medicare Outpatient Cost to Charge Ratio of 52%","728.00","52","","","Percent of Total Billed Charges","neg_dollar:$728;100% Medicare Outpatient Cost to Charge Ratio of 52%","728.00","1400.00",""
"CHOLANGIOGRAM INTRAOP ADDTL","74301","CPT","70000352","CDM","320","RC","","Facility","Outpatient","","","489","391.20","489.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","254.28","52","","","Percent of Total Billed Charges","neg_dollar:$254.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","489.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","254.28","52","","","Percent of Total Billed Charges","neg_dollar:$254.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","254.28","52","","","Percent of Total Billed Charges","neg_dollar:$254.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","254.28","52","","","Percent of Total Billed Charges","neg_dollar:$254.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","420.54","86","","","Percent of Total Billed Charges","neg_dollar:$420.54","342.29","70","","","Percent of Total Billed Charges","neg_dollar:$342.29","254.28","52","","","Percent of Total Billed Charges","neg_dollar:$254.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","287.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$287.28;102% of Medicaid interim rate","366.75","75","","","Percent of Total Billed Charges","neg_dollar:$366.75","420.54","86","","","Percent of Total Billed Charges","neg_dollar:$420.54","342.29","70","","","Percent of Total Billed Charges","neg_dollar:$342.29","278.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$278.72;103.5% of Medicaid interim rate","489.00","150","","","Percent of Total Billed Charges","neg_dollar:$756.01;150% of Medicaid interim rate","391.20","80","","","Percent of Total Billed Charges","neg_dollar:$391.20;Percent of Total Billed Charges","","","","489.00","Fee Schedule","","254.28","52","","","Percent of Total Billed Charges","neg_dollar:$254.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","254.28","52","","","Percent of Total Billed Charges","neg_dollar:$254.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","254.00","489.00",""
"IVP W WO TOMOGRAPHY OR KUB","74400","CPT","70000178","CDM","320","RC","","Facility","Outpatient","","","1243","994.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1068.98","86","","","Percent of Total Billed Charges","neg_dollar:$1068.98","870.09","70","","","Percent of Total Billed Charges","neg_dollar:$870.09","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","730.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$730.26;102% of Medicaid interim rate","932.25","75","","","Percent of Total Billed Charges","neg_dollar:$932.25","1068.98","86","","","Percent of Total Billed Charges","neg_dollar:$1068.98","870.09","70","","","Percent of Total Billed Charges","neg_dollar:$870.09","708.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$708.51;103.5% of Medicaid interim rate","1243.00","150","","","Percent of Total Billed Charges","neg_dollar:$1921.74;150% of Medicaid interim rate","994.40","80","","","Percent of Total Billed Charges","neg_dollar:$994.40;Percent of Total Billed Charges","","","","1243.00","Fee Schedule","","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","646.00","1243.00",""
"CT ANGIOGRAPHY AORTA ILIOFEMORAL RUNOFF","75635","CPT","70000189","CDM","352","RC","","Facility","Outpatient","","","4223","3378.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","3631.77","86","","","Percent of Total Billed Charges","neg_dollar:$3631.77","2956.10","70","","","Percent of Total Billed Charges","neg_dollar:$2956.10","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","2481.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$2481;102% of Medicaid interim rate","3167.25","75","","","Percent of Total Billed Charges","neg_dollar:$3167.25","3631.77","86","","","Percent of Total Billed Charges","neg_dollar:$3631.77","2956.10","70","","","Percent of Total Billed Charges","neg_dollar:$2956.10","2407.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$2407.10;103.5% of Medicaid interim rate","4223.00","150","","","Percent of Total Billed Charges","neg_dollar:$6528.96;150% of Medicaid interim rate","3378.40","80","","","Percent of Total Billed Charges","neg_dollar:$3378.40;Percent of Total Billed Charges","","","","2106.00","Fee Schedule","","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4223.00",""
"DRAINAGE CATH PLACEMENT W IMG GUIDANCE","75989","CPT","70000201","CDM","350","RC","","Facility","Outpatient","","","1696","1356.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1458.56","86","","","Percent of Total Billed Charges","neg_dollar:$1458.56","1187.19","70","","","Percent of Total Billed Charges","neg_dollar:$1187.19","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","996.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$996.39;102% of Medicaid interim rate","1272.00","75","","","Percent of Total Billed Charges","neg_dollar:$1272","1458.56","86","","","Percent of Total Billed Charges","neg_dollar:$1458.56","1187.19","70","","","Percent of Total Billed Charges","neg_dollar:$1187.19","966.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$966.71;103.5% of Medicaid interim rate","1696.00","150","","","Percent of Total Billed Charges","neg_dollar:$2622.10;150% of Medicaid interim rate","1356.80","80","","","Percent of Total Billed Charges","neg_dollar:$1356.80;Percent of Total Billed Charges","","","","1696.00","Fee Schedule","","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","881.92","52","","","Percent of Total Billed Charges","neg_dollar:$881.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1696.00",""
"FLUOROSCOPE EXAMINATION","76000","CPT","70000202","CDM","320","RC","","Facility","Outpatient","","","738","590.40","738.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","383.76","52","","","Percent of Total Billed Charges","neg_dollar:$383.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","738.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","383.76","52","","","Percent of Total Billed Charges","neg_dollar:$383.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","383.76","52","","","Percent of Total Billed Charges","neg_dollar:$383.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","383.76","52","","","Percent of Total Billed Charges","neg_dollar:$383.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","634.68","86","","","Percent of Total Billed Charges","neg_dollar:$634.68","516.60","70","","","Percent of Total Billed Charges","neg_dollar:$516.60","383.76","52","","","Percent of Total Billed Charges","neg_dollar:$383.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","433.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$433.57;102% of Medicaid interim rate","553.50","75","","","Percent of Total Billed Charges","neg_dollar:$553.50","634.68","86","","","Percent of Total Billed Charges","neg_dollar:$634.68","516.60","70","","","Percent of Total Billed Charges","neg_dollar:$516.60","420.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$420.65;103.5% of Medicaid interim rate","738.00","150","","","Percent of Total Billed Charges","neg_dollar:$1140.98;150% of Medicaid interim rate","590.40","80","","","Percent of Total Billed Charges","neg_dollar:$590.40;Percent of Total Billed Charges","","","","738.00","Fee Schedule","","383.76","52","","","Percent of Total Billed Charges","neg_dollar:$383.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","383.76","52","","","Percent of Total Billed Charges","neg_dollar:$383.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","383.00","738.00",""
"NOSE TO RECTUM FOREIGN BODY CHILD","76010","CPT","70000203","CDM","320","RC","","Facility","Outpatient","","","226","180.80","226.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","226.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","194.35","86","","","Percent of Total Billed Charges","neg_dollar:$194.35","158.20","70","","","Percent of Total Billed Charges","neg_dollar:$158.20","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","132.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$132.77;102% of Medicaid interim rate","169.50","75","","","Percent of Total Billed Charges","neg_dollar:$169.50","194.35","86","","","Percent of Total Billed Charges","neg_dollar:$194.35","158.20","70","","","Percent of Total Billed Charges","neg_dollar:$158.20","128.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$128.82;103.5% of Medicaid interim rate","226.00","150","","","Percent of Total Billed Charges","neg_dollar:$349.40;150% of Medicaid interim rate","180.80","80","","","Percent of Total Billed Charges","neg_dollar:$180.80;Percent of Total Billed Charges","","","","226.00","Fee Schedule","","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","117.00","226.00",""
"SURGICAL SPECIMEN","76098","CPT","70000205","CDM","320","RC","","Facility","Outpatient","","","1160","928.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","603.20","52","","","Percent of Total Billed Charges","neg_dollar:$603.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","603.20","52","","","Percent of Total Billed Charges","neg_dollar:$603.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","603.20","52","","","Percent of Total Billed Charges","neg_dollar:$603.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","603.20","52","","","Percent of Total Billed Charges","neg_dollar:$603.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","997.60","86","","","Percent of Total Billed Charges","neg_dollar:$997.60","812.00","70","","","Percent of Total Billed Charges","neg_dollar:$812","603.20","52","","","Percent of Total Billed Charges","neg_dollar:$603.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","681.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$681.49;102% of Medicaid interim rate","870.00","75","","","Percent of Total Billed Charges","neg_dollar:$870","997.60","86","","","Percent of Total Billed Charges","neg_dollar:$997.60","812.00","70","","","Percent of Total Billed Charges","neg_dollar:$812","661.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$661.19;103.5% of Medicaid interim rate","1160.00","150","","","Percent of Total Billed Charges","neg_dollar:$1793.41;150% of Medicaid interim rate","928.00","80","","","Percent of Total Billed Charges","neg_dollar:$928;Percent of Total Billed Charges","","","","1160.00","Fee Schedule","","603.20","52","","","Percent of Total Billed Charges","neg_dollar:$603.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","603.20","52","","","Percent of Total Billed Charges","neg_dollar:$603.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","603.00","1160.00",""
"3D RENDER WO POSTPROCESS","76376","CPT","70000207","CDM","350","RC","","Facility","Outpatient","","","414","331.20","414.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","414.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","356.04","86","","","Percent of Total Billed Charges","neg_dollar:$356.04","289.79","70","","","Percent of Total Billed Charges","neg_dollar:$289.79","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","243.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$243.22;102% of Medicaid interim rate","310.50","75","","","Percent of Total Billed Charges","neg_dollar:$310.50","356.04","86","","","Percent of Total Billed Charges","neg_dollar:$356.04","289.79","70","","","Percent of Total Billed Charges","neg_dollar:$289.79","235.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$235.98;103.5% of Medicaid interim rate","414.00","150","","","Percent of Total Billed Charges","neg_dollar:$640.06;150% of Medicaid interim rate","331.20","80","","","Percent of Total Billed Charges","neg_dollar:$331.20;Percent of Total Billed Charges","","","","414.00","Fee Schedule","","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","215.28","52","","","Percent of Total Billed Charges","neg_dollar:$215.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","215.00","414.00",""
"CT LIMITED OR FOLLOWUP STUDY","76380","CPT","70000366","CDM","350","RC","","Facility","Outpatient","","","1234","987.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","641.68","52","","","Percent of Total Billed Charges","neg_dollar:$641.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","641.68","52","","","Percent of Total Billed Charges","neg_dollar:$641.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","641.68","52","","","Percent of Total Billed Charges","neg_dollar:$641.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","641.68","52","","","Percent of Total Billed Charges","neg_dollar:$641.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1061.24","86","","","Percent of Total Billed Charges","neg_dollar:$1061.24","863.80","70","","","Percent of Total Billed Charges","neg_dollar:$863.80","641.68","52","","","Percent of Total Billed Charges","neg_dollar:$641.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","724.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$724.97;102% of Medicaid interim rate","925.50","75","","","Percent of Total Billed Charges","neg_dollar:$925.50","1061.24","86","","","Percent of Total Billed Charges","neg_dollar:$1061.24","863.80","70","","","Percent of Total Billed Charges","neg_dollar:$863.80","703.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$703.38;103.5% of Medicaid interim rate","1234.00","150","","","Percent of Total Billed Charges","neg_dollar:$1907.82;150% of Medicaid interim rate","987.20","80","","","Percent of Total Billed Charges","neg_dollar:$987.20;Percent of Total Billed Charges","","","","1234.00","Fee Schedule","","641.68","52","","","Percent of Total Billed Charges","neg_dollar:$641.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","641.68","52","","","Percent of Total Billed Charges","neg_dollar:$641.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","641.00","1234.00",""
"US EXAM OF HEAD ECHOENCEPHALOGRAM","76506","CPT","70000368","CDM","402","RC","","Facility","Outpatient","","","512","409.60","512.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","266.24","52","","","Percent of Total Billed Charges","neg_dollar:$266.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","512.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","266.24","52","","","Percent of Total Billed Charges","neg_dollar:$266.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","266.24","52","","","Percent of Total Billed Charges","neg_dollar:$266.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","266.24","52","","","Percent of Total Billed Charges","neg_dollar:$266.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.32","86","","","Percent of Total Billed Charges","neg_dollar:$440.32","358.40","70","","","Percent of Total Billed Charges","neg_dollar:$358.40","266.24","52","","","Percent of Total Billed Charges","neg_dollar:$266.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","300.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$300.79;102% of Medicaid interim rate","384.00","75","","","Percent of Total Billed Charges","neg_dollar:$384","440.32","86","","","Percent of Total Billed Charges","neg_dollar:$440.32","358.40","70","","","Percent of Total Billed Charges","neg_dollar:$358.40","291.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$291.84;103.5% of Medicaid interim rate","512.00","150","","","Percent of Total Billed Charges","neg_dollar:$791.57;150% of Medicaid interim rate","409.60","80","","","Percent of Total Billed Charges","neg_dollar:$409.60;Percent of Total Billed Charges","","","","512.00","Fee Schedule","","266.24","52","","","Percent of Total Billed Charges","neg_dollar:$266.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","266.24","52","","","Percent of Total Billed Charges","neg_dollar:$266.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","266.00","512.00",""
"US EXAM OF HEAD AND NECK","76536","CPT","70000209","CDM","402","RC","","Facility","Outpatient","","","847","677.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","497.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$497.61;102% of Medicaid interim rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","482.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$482.78;103.5% of Medicaid interim rate","847.00","150","","","Percent of Total Billed Charges","neg_dollar:$1309.50;150% of Medicaid interim rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","","","","707.00","Fee Schedule","","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.44","52","","","Percent of Total Billed Charges","neg_dollar:$440.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","440.00","847.00",""
"US EXAM CHEST","76604","CPT","70000294","CDM","402","RC","","Facility","Outpatient","","","782","625.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","406.64","52","","","Percent of Total Billed Charges","neg_dollar:$406.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","782.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","406.64","52","","","Percent of Total Billed Charges","neg_dollar:$406.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","406.64","52","","","Percent of Total Billed Charges","neg_dollar:$406.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","406.64","52","","","Percent of Total Billed Charges","neg_dollar:$406.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","672.52","86","","","Percent of Total Billed Charges","neg_dollar:$672.52","547.40","70","","","Percent of Total Billed Charges","neg_dollar:$547.40","406.64","52","","","Percent of Total Billed Charges","neg_dollar:$406.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","459.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$459.42;102% of Medicaid interim rate","586.50","75","","","Percent of Total Billed Charges","neg_dollar:$586.50","672.52","86","","","Percent of Total Billed Charges","neg_dollar:$672.52","547.40","70","","","Percent of Total Billed Charges","neg_dollar:$547.40","445.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$445.73;103.5% of Medicaid interim rate","782.00","150","","","Percent of Total Billed Charges","neg_dollar:$1209.01;150% of Medicaid interim rate","625.60","80","","","Percent of Total Billed Charges","neg_dollar:$625.60;Percent of Total Billed Charges","","","","390.00","Fee Schedule","","406.64","52","","","Percent of Total Billed Charges","neg_dollar:$406.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","406.64","52","","","Percent of Total Billed Charges","neg_dollar:$406.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","782.00",""
"US BREAST COMPLETE","76641","CPT","70000720","CDM","402","RC","","Facility","Outpatient","","","987","789.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","513.24","52","","","Percent of Total Billed Charges","neg_dollar:$513.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","513.24","52","","","Percent of Total Billed Charges","neg_dollar:$513.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","513.24","52","","","Percent of Total Billed Charges","neg_dollar:$513.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","513.24","52","","","Percent of Total Billed Charges","neg_dollar:$513.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","848.81","86","","","Percent of Total Billed Charges","neg_dollar:$848.81","690.90","70","","","Percent of Total Billed Charges","neg_dollar:$690.90","513.24","52","","","Percent of Total Billed Charges","neg_dollar:$513.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","579.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$579.86;102% of Medicaid interim rate","740.25","75","","","Percent of Total Billed Charges","neg_dollar:$740.25","848.81","86","","","Percent of Total Billed Charges","neg_dollar:$848.81","690.90","70","","","Percent of Total Billed Charges","neg_dollar:$690.90","562.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$562.58;103.5% of Medicaid interim rate","987.00","150","","","Percent of Total Billed Charges","neg_dollar:$1525.95;150% of Medicaid interim rate","789.60","80","","","Percent of Total Billed Charges","neg_dollar:$789.60;Percent of Total Billed Charges","","","","987.00","Fee Schedule","","513.24","52","","","Percent of Total Billed Charges","neg_dollar:$513.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","513.24","52","","","Percent of Total Billed Charges","neg_dollar:$513.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","513.00","987.00",""
"US BREAST COMPLETE","76641","CPT","70000720","CDM","402","RC","","Facility","Outpatient","","","1408","1126.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1210.87","86","","","Percent of Total Billed Charges","neg_dollar:$1210.87","985.59","70","","","Percent of Total Billed Charges","neg_dollar:$985.59","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","827.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$827.19;102% of Medicaid interim rate","1056.00","75","","","Percent of Total Billed Charges","neg_dollar:$1056","1210.87","86","","","Percent of Total Billed Charges","neg_dollar:$1210.87","985.59","70","","","Percent of Total Billed Charges","neg_dollar:$985.59","802.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$802.56;103.5% of Medicaid interim rate","1408.00","150","","","Percent of Total Billed Charges","neg_dollar:$2176.83;150% of Medicaid interim rate","1126.40","80","","","Percent of Total Billed Charges","neg_dollar:$1126.40;Percent of Total Billed Charges","","","","1408.00","Fee Schedule","","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","732.00","1408.00",""
"US BREAST LIMITED","76642","CPT","70000721","CDM","402","RC","","Facility","Outpatient","","","646","516.80","646.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","646.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","555.56","86","","","Percent of Total Billed Charges","neg_dollar:$555.56","452.20","70","","","Percent of Total Billed Charges","neg_dollar:$452.20","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","379.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$379.52;102% of Medicaid interim rate","484.50","75","","","Percent of Total Billed Charges","neg_dollar:$484.50","555.56","86","","","Percent of Total Billed Charges","neg_dollar:$555.56","452.20","70","","","Percent of Total Billed Charges","neg_dollar:$452.20","368.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$368.21;103.5% of Medicaid interim rate","646.00","150","","","Percent of Total Billed Charges","neg_dollar:$998.74;150% of Medicaid interim rate","516.80","80","","","Percent of Total Billed Charges","neg_dollar:$516.80;Percent of Total Billed Charges","","","","646.00","Fee Schedule","","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","335.00","646.00",""
"US BREAST LIMITED","76642","CPT","70000721","CDM","402","RC","","Facility","Outpatient","","","922","737.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","479.44","52","","","Percent of Total Billed Charges","neg_dollar:$479.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","479.44","52","","","Percent of Total Billed Charges","neg_dollar:$479.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","479.44","52","","","Percent of Total Billed Charges","neg_dollar:$479.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","479.44","52","","","Percent of Total Billed Charges","neg_dollar:$479.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","792.92","86","","","Percent of Total Billed Charges","neg_dollar:$792.92","645.40","70","","","Percent of Total Billed Charges","neg_dollar:$645.40","479.44","52","","","Percent of Total Billed Charges","neg_dollar:$479.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","541.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$541.67;102% of Medicaid interim rate","691.50","75","","","Percent of Total Billed Charges","neg_dollar:$691.50","792.92","86","","","Percent of Total Billed Charges","neg_dollar:$792.92","645.40","70","","","Percent of Total Billed Charges","neg_dollar:$645.40","525.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$525.54;103.5% of Medicaid interim rate","922.00","150","","","Percent of Total Billed Charges","neg_dollar:$1425.45;150% of Medicaid interim rate","737.60","80","","","Percent of Total Billed Charges","neg_dollar:$737.60;Percent of Total Billed Charges","","","","922.00","Fee Schedule","","479.44","52","","","Percent of Total Billed Charges","neg_dollar:$479.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","479.44","52","","","Percent of Total Billed Charges","neg_dollar:$479.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","479.00","922.00",""
"US EXAM ABDOMEN COMPLETE","76700","CPT","70000211","CDM","402","RC","","Facility","Outpatient","","","1243","994.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1068.98","86","","","Percent of Total Billed Charges","neg_dollar:$1068.98","870.09","70","","","Percent of Total Billed Charges","neg_dollar:$870.09","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","730.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$730.26;102% of Medicaid interim rate","932.25","75","","","Percent of Total Billed Charges","neg_dollar:$932.25","1068.98","86","","","Percent of Total Billed Charges","neg_dollar:$1068.98","870.09","70","","","Percent of Total Billed Charges","neg_dollar:$870.09","708.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$708.51;103.5% of Medicaid interim rate","1243.00","150","","","Percent of Total Billed Charges","neg_dollar:$1921.74;150% of Medicaid interim rate","994.40","80","","","Percent of Total Billed Charges","neg_dollar:$994.40;Percent of Total Billed Charges","","","","987.00","Fee Schedule","","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","646.36","52","","","Percent of Total Billed Charges","neg_dollar:$646.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","646.00","1243.00",""
"US EXAM ABDOMEN LIMITED","76705","CPT","70000295","CDM","402","RC","","Facility","Outpatient","","","803","642.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","803.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","690.58","86","","","Percent of Total Billed Charges","neg_dollar:$690.58","562.09","70","","","Percent of Total Billed Charges","neg_dollar:$562.09","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","471.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$471.76;102% of Medicaid interim rate","602.25","75","","","Percent of Total Billed Charges","neg_dollar:$602.25","690.58","86","","","Percent of Total Billed Charges","neg_dollar:$690.58","562.09","70","","","Percent of Total Billed Charges","neg_dollar:$562.09","457.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$457.71;103.5% of Medicaid interim rate","803.00","150","","","Percent of Total Billed Charges","neg_dollar:$1241.47;150% of Medicaid interim rate","642.40","80","","","Percent of Total Billed Charges","neg_dollar:$642.40;Percent of Total Billed Charges","","","","622.00","Fee Schedule","","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","417.00","803.00",""
"US ABDL AORTA SCREEN AAA","76706","CPT","70000786","CDM","402","RC","","Facility","Outpatient","","","699","559.20","699.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","699.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","601.14","86","","","Percent of Total Billed Charges","neg_dollar:$601.14","489.29","70","","","Percent of Total Billed Charges","neg_dollar:$489.29","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","410.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$410.66;102% of Medicaid interim rate","524.25","75","","","Percent of Total Billed Charges","neg_dollar:$524.25","601.14","86","","","Percent of Total Billed Charges","neg_dollar:$601.14","489.29","70","","","Percent of Total Billed Charges","neg_dollar:$489.29","398.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$398.42;103.5% of Medicaid interim rate","699.00","150","","","Percent of Total Billed Charges","neg_dollar:$1080.68;150% of Medicaid interim rate","559.20","80","","","Percent of Total Billed Charges","neg_dollar:$559.20;Percent of Total Billed Charges","","","","555.00","Fee Schedule","","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","363.00","699.00",""
"US EXAM RETROPERITONEAL COMPL","76770","CPT","70000212","CDM","402","RC","","Facility","Outpatient","","","1012","809.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","870.31","86","","","Percent of Total Billed Charges","neg_dollar:$870.31","708.40","70","","","Percent of Total Billed Charges","neg_dollar:$708.40","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","594.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$594.54;102% of Medicaid interim rate","759.00","75","","","Percent of Total Billed Charges","neg_dollar:$759","870.31","86","","","Percent of Total Billed Charges","neg_dollar:$870.31","708.40","70","","","Percent of Total Billed Charges","neg_dollar:$708.40","576.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$576.83;103.5% of Medicaid interim rate","1012.00","150","","","Percent of Total Billed Charges","neg_dollar:$1564.60;150% of Medicaid interim rate","809.60","80","","","Percent of Total Billed Charges","neg_dollar:$809.60;Percent of Total Billed Charges","","","","505.00","Fee Schedule","","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","505.00","1012.00",""
"US EXAM RETROPERITONEAL LTD","76775","CPT","70000296","CDM","402","RC","","Facility","Outpatient","","","699","559.20","699.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","699.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","601.14","86","","","Percent of Total Billed Charges","neg_dollar:$601.14","489.29","70","","","Percent of Total Billed Charges","neg_dollar:$489.29","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","410.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$410.66;102% of Medicaid interim rate","524.25","75","","","Percent of Total Billed Charges","neg_dollar:$524.25","601.14","86","","","Percent of Total Billed Charges","neg_dollar:$601.14","489.29","70","","","Percent of Total Billed Charges","neg_dollar:$489.29","398.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$398.42;103.5% of Medicaid interim rate","699.00","150","","","Percent of Total Billed Charges","neg_dollar:$1080.68;150% of Medicaid interim rate","559.20","80","","","Percent of Total Billed Charges","neg_dollar:$559.20;Percent of Total Billed Charges","","","","349.00","Fee Schedule","","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","363.48","52","","","Percent of Total Billed Charges","neg_dollar:$363.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","349.00","699.00",""
"US EXAM KIDNEY TRANSPL W DOPPLER","76776","CPT","70000369","CDM","402","RC","","Facility","Outpatient","","","755","604.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","755.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","649.30","86","","","Percent of Total Billed Charges","neg_dollar:$649.30","528.50","70","","","Percent of Total Billed Charges","neg_dollar:$528.50","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","443.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$443.56;102% of Medicaid interim rate","566.25","75","","","Percent of Total Billed Charges","neg_dollar:$566.25","649.30","86","","","Percent of Total Billed Charges","neg_dollar:$649.30","528.50","70","","","Percent of Total Billed Charges","neg_dollar:$528.50","430.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$430.34;103.5% of Medicaid interim rate","755.00","150","","","Percent of Total Billed Charges","neg_dollar:$1167.26;150% of Medicaid interim rate","604.00","80","","","Percent of Total Billed Charges","neg_dollar:$604;Percent of Total Billed Charges","","","","755.00","Fee Schedule","","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","392.00","755.00",""
"US OB LESS THAN 14 WKS SNGL FETUS","76801","CPT","70000214","CDM","402","RC","","Facility","Outpatient","","","670","536.00","670.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","348.40","52","","","Percent of Total Billed Charges","neg_dollar:$348.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","670.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","348.40","52","","","Percent of Total Billed Charges","neg_dollar:$348.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","348.40","52","","","Percent of Total Billed Charges","neg_dollar:$348.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","348.40","52","","","Percent of Total Billed Charges","neg_dollar:$348.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","576.20","86","","","Percent of Total Billed Charges","neg_dollar:$576.20","468.99","70","","","Percent of Total Billed Charges","neg_dollar:$468.99","348.40","52","","","Percent of Total Billed Charges","neg_dollar:$348.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","393.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$393.62;102% of Medicaid interim rate","502.50","75","","","Percent of Total Billed Charges","neg_dollar:$502.50","576.20","86","","","Percent of Total Billed Charges","neg_dollar:$576.20","468.99","70","","","Percent of Total Billed Charges","neg_dollar:$468.99","381.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$381.90;103.5% of Medicaid interim rate","670.00","150","","","Percent of Total Billed Charges","neg_dollar:$1035.85;150% of Medicaid interim rate","536.00","80","","","Percent of Total Billed Charges","neg_dollar:$536;Percent of Total Billed Charges","","","","670.00","Fee Schedule","","348.40","52","","","Percent of Total Billed Charges","neg_dollar:$348.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","348.40","52","","","Percent of Total Billed Charges","neg_dollar:$348.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","348.00","670.00",""
"US OB LESS THAN 14 WKS ADDL FETUS","76802","CPT","70000215","CDM","402","RC","","Facility","Outpatient","","","516","412.80","516.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","268.32","52","","","Percent of Total Billed Charges","neg_dollar:$268.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","516.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","268.32","52","","","Percent of Total Billed Charges","neg_dollar:$268.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","268.32","52","","","Percent of Total Billed Charges","neg_dollar:$268.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","268.32","52","","","Percent of Total Billed Charges","neg_dollar:$268.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","443.76","86","","","Percent of Total Billed Charges","neg_dollar:$443.76","361.20","70","","","Percent of Total Billed Charges","neg_dollar:$361.20","268.32","52","","","Percent of Total Billed Charges","neg_dollar:$268.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","303.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$303.14;102% of Medicaid interim rate","387.00","75","","","Percent of Total Billed Charges","neg_dollar:$387","443.76","86","","","Percent of Total Billed Charges","neg_dollar:$443.76","361.20","70","","","Percent of Total Billed Charges","neg_dollar:$361.20","294.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$294.11;103.5% of Medicaid interim rate","516.00","150","","","Percent of Total Billed Charges","neg_dollar:$797.76;150% of Medicaid interim rate","412.80","80","","","Percent of Total Billed Charges","neg_dollar:$412.80;Percent of Total Billed Charges","","","","516.00","Fee Schedule","","268.32","52","","","Percent of Total Billed Charges","neg_dollar:$268.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","268.32","52","","","Percent of Total Billed Charges","neg_dollar:$268.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","268.00","516.00",""
"US OB COMPLETE SNGL FETUS","76805","CPT","70000216","CDM","402","RC","","Facility","Outpatient","","","1122","897.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","583.44","52","","","Percent of Total Billed Charges","neg_dollar:$583.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","583.44","52","","","Percent of Total Billed Charges","neg_dollar:$583.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","583.44","52","","","Percent of Total Billed Charges","neg_dollar:$583.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","583.44","52","","","Percent of Total Billed Charges","neg_dollar:$583.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","964.92","86","","","Percent of Total Billed Charges","neg_dollar:$964.92","785.40","70","","","Percent of Total Billed Charges","neg_dollar:$785.40","583.44","52","","","Percent of Total Billed Charges","neg_dollar:$583.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","659.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$659.17;102% of Medicaid interim rate","841.50","75","","","Percent of Total Billed Charges","neg_dollar:$841.50","964.92","86","","","Percent of Total Billed Charges","neg_dollar:$964.92","785.40","70","","","Percent of Total Billed Charges","neg_dollar:$785.40","639.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$639.54;103.5% of Medicaid interim rate","1122.00","150","","","Percent of Total Billed Charges","neg_dollar:$1734.66;150% of Medicaid interim rate","897.60","80","","","Percent of Total Billed Charges","neg_dollar:$897.60;Percent of Total Billed Charges","","","","1122.00","Fee Schedule","","583.44","52","","","Percent of Total Billed Charges","neg_dollar:$583.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","583.44","52","","","Percent of Total Billed Charges","neg_dollar:$583.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","583.00","1122.00",""
"US OB COMPLETE ADDL FETUS","76810","CPT","70000370","CDM","402","RC","","Facility","Outpatient","","","960","768.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","499.20","52","","","Percent of Total Billed Charges","neg_dollar:$499.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","499.20","52","","","Percent of Total Billed Charges","neg_dollar:$499.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","499.20","52","","","Percent of Total Billed Charges","neg_dollar:$499.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","499.20","52","","","Percent of Total Billed Charges","neg_dollar:$499.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","825.60","86","","","Percent of Total Billed Charges","neg_dollar:$825.60","672.00","70","","","Percent of Total Billed Charges","neg_dollar:$672","499.20","52","","","Percent of Total Billed Charges","neg_dollar:$499.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","563.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$563.99;102% of Medicaid interim rate","720.00","75","","","Percent of Total Billed Charges","neg_dollar:$720","825.60","86","","","Percent of Total Billed Charges","neg_dollar:$825.60","672.00","70","","","Percent of Total Billed Charges","neg_dollar:$672","547.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$547.19;103.5% of Medicaid interim rate","960.00","150","","","Percent of Total Billed Charges","neg_dollar:$1484.20;150% of Medicaid interim rate","768.00","80","","","Percent of Total Billed Charges","neg_dollar:$768;Percent of Total Billed Charges","","","","960.00","Fee Schedule","","499.20","52","","","Percent of Total Billed Charges","neg_dollar:$499.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","499.20","52","","","Percent of Total Billed Charges","neg_dollar:$499.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","499.00","960.00",""
"US OB LIMITED FETUS(S)","76815","CPT","70000297","CDM","402","RC","","Facility","Outpatient","","","648","518.40","648.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","648.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","557.28","86","","","Percent of Total Billed Charges","neg_dollar:$557.28","453.59","70","","","Percent of Total Billed Charges","neg_dollar:$453.59","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","380.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$380.69;102% of Medicaid interim rate","486.00","75","","","Percent of Total Billed Charges","neg_dollar:$486","557.28","86","","","Percent of Total Billed Charges","neg_dollar:$557.28","453.59","70","","","Percent of Total Billed Charges","neg_dollar:$453.59","369.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$369.35;103.5% of Medicaid interim rate","648.00","150","","","Percent of Total Billed Charges","neg_dollar:$1001.84;150% of Medicaid interim rate","518.40","80","","","Percent of Total Billed Charges","neg_dollar:$518.40;Percent of Total Billed Charges","","","","433.00","Fee Schedule","","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","336.00","648.00",""
"US OB FOLLOW UP PER FETUS","76816","CPT","70000219","CDM","402","RC","","Facility","Outpatient","","","667","533.60","667.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","346.84","52","","","Percent of Total Billed Charges","neg_dollar:$346.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","667.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","346.84","52","","","Percent of Total Billed Charges","neg_dollar:$346.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","346.84","52","","","Percent of Total Billed Charges","neg_dollar:$346.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","346.84","52","","","Percent of Total Billed Charges","neg_dollar:$346.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","573.62","86","","","Percent of Total Billed Charges","neg_dollar:$573.62","466.90","70","","","Percent of Total Billed Charges","neg_dollar:$466.90","346.84","52","","","Percent of Total Billed Charges","neg_dollar:$346.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","391.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$391.86;102% of Medicaid interim rate","500.25","75","","","Percent of Total Billed Charges","neg_dollar:$500.25","573.62","86","","","Percent of Total Billed Charges","neg_dollar:$573.62","466.90","70","","","Percent of Total Billed Charges","neg_dollar:$466.90","380.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$380.18;103.5% of Medicaid interim rate","667.00","150","","","Percent of Total Billed Charges","neg_dollar:$1031.21;150% of Medicaid interim rate","533.60","80","","","Percent of Total Billed Charges","neg_dollar:$533.60;Percent of Total Billed Charges","","","","667.00","Fee Schedule","","346.84","52","","","Percent of Total Billed Charges","neg_dollar:$346.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","346.84","52","","","Percent of Total Billed Charges","neg_dollar:$346.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","346.00","667.00",""
"US OB TRANSVAGINAL","76817","CPT","70000220","CDM","402","RC","","Facility","Outpatient","","","632","505.60","632.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","328.64","52","","","Percent of Total Billed Charges","neg_dollar:$328.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","632.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","328.64","52","","","Percent of Total Billed Charges","neg_dollar:$328.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","328.64","52","","","Percent of Total Billed Charges","neg_dollar:$328.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","328.64","52","","","Percent of Total Billed Charges","neg_dollar:$328.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","543.52","86","","","Percent of Total Billed Charges","neg_dollar:$543.52","442.40","70","","","Percent of Total Billed Charges","neg_dollar:$442.40","328.64","52","","","Percent of Total Billed Charges","neg_dollar:$328.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","371.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$371.29;102% of Medicaid interim rate","474.00","75","","","Percent of Total Billed Charges","neg_dollar:$474","543.52","86","","","Percent of Total Billed Charges","neg_dollar:$543.52","442.40","70","","","Percent of Total Billed Charges","neg_dollar:$442.40","360.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$360.23;103.5% of Medicaid interim rate","632.00","150","","","Percent of Total Billed Charges","neg_dollar:$977.10;150% of Medicaid interim rate","505.60","80","","","Percent of Total Billed Charges","neg_dollar:$505.60;Percent of Total Billed Charges","","","","527.00","Fee Schedule","","328.64","52","","","Percent of Total Billed Charges","neg_dollar:$328.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","328.64","52","","","Percent of Total Billed Charges","neg_dollar:$328.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","328.00","632.00",""
"US FBP W NON-STRESS TEST","76818","CPT","70000529","CDM","402","RC","","Facility","Outpatient","","","1262","1009.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","656.24","52","","","Percent of Total Billed Charges","neg_dollar:$656.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","656.24","52","","","Percent of Total Billed Charges","neg_dollar:$656.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","656.24","52","","","Percent of Total Billed Charges","neg_dollar:$656.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","656.24","52","","","Percent of Total Billed Charges","neg_dollar:$656.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1085.32","86","","","Percent of Total Billed Charges","neg_dollar:$1085.32","883.40","70","","","Percent of Total Billed Charges","neg_dollar:$883.40","656.24","52","","","Percent of Total Billed Charges","neg_dollar:$656.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","741.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$741.42;102% of Medicaid interim rate","946.50","75","","","Percent of Total Billed Charges","neg_dollar:$946.50","1085.32","86","","","Percent of Total Billed Charges","neg_dollar:$1085.32","883.40","70","","","Percent of Total Billed Charges","neg_dollar:$883.40","719.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$719.33;103.5% of Medicaid interim rate","1262.00","150","","","Percent of Total Billed Charges","neg_dollar:$1951.11;150% of Medicaid interim rate","1009.60","80","","","Percent of Total Billed Charges","neg_dollar:$1009.60;Percent of Total Billed Charges","","","","1262.00","Fee Schedule","","656.24","52","","","Percent of Total Billed Charges","neg_dollar:$656.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","656.24","52","","","Percent of Total Billed Charges","neg_dollar:$656.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","656.00","1262.00",""
"US FBP WO NONSTRESS TEST","76819","CPT","70000221","CDM","402","RC","","Facility","Outpatient","","","735","588.00","735.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","382.20","52","","","Percent of Total Billed Charges","neg_dollar:$382.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","735.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","382.20","52","","","Percent of Total Billed Charges","neg_dollar:$382.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","382.20","52","","","Percent of Total Billed Charges","neg_dollar:$382.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","382.20","52","","","Percent of Total Billed Charges","neg_dollar:$382.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","632.10","86","","","Percent of Total Billed Charges","neg_dollar:$632.10","514.50","70","","","Percent of Total Billed Charges","neg_dollar:$514.50","382.20","52","","","Percent of Total Billed Charges","neg_dollar:$382.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","431.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$431.81;102% of Medicaid interim rate","551.25","75","","","Percent of Total Billed Charges","neg_dollar:$551.25","632.10","86","","","Percent of Total Billed Charges","neg_dollar:$632.10","514.50","70","","","Percent of Total Billed Charges","neg_dollar:$514.50","418.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$418.95;103.5% of Medicaid interim rate","735.00","150","","","Percent of Total Billed Charges","neg_dollar:$1136.34;150% of Medicaid interim rate","588.00","80","","","Percent of Total Billed Charges","neg_dollar:$588;Percent of Total Billed Charges","","","","735.00","Fee Schedule","","382.20","52","","","Percent of Total Billed Charges","neg_dollar:$382.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","382.20","52","","","Percent of Total Billed Charges","neg_dollar:$382.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","382.00","735.00",""
"US NON OB TRANSVAG","76830","CPT","70000298","CDM","402","RC","","Facility","Outpatient","","","930","744.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","483.60","52","","","Percent of Total Billed Charges","neg_dollar:$483.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","483.60","52","","","Percent of Total Billed Charges","neg_dollar:$483.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","483.60","52","","","Percent of Total Billed Charges","neg_dollar:$483.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","483.60","52","","","Percent of Total Billed Charges","neg_dollar:$483.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","799.80","86","","","Percent of Total Billed Charges","neg_dollar:$799.80","651.00","70","","","Percent of Total Billed Charges","neg_dollar:$651","483.60","52","","","Percent of Total Billed Charges","neg_dollar:$483.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","546.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$546.37;102% of Medicaid interim rate","697.50","75","","","Percent of Total Billed Charges","neg_dollar:$697.50","799.80","86","","","Percent of Total Billed Charges","neg_dollar:$799.80","651.00","70","","","Percent of Total Billed Charges","neg_dollar:$651","530.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$530.09;103.5% of Medicaid interim rate","930.00","150","","","Percent of Total Billed Charges","neg_dollar:$1437.82;150% of Medicaid interim rate","744.00","80","","","Percent of Total Billed Charges","neg_dollar:$744;Percent of Total Billed Charges","","","","738.00","Fee Schedule","","483.60","52","","","Percent of Total Billed Charges","neg_dollar:$483.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","483.60","52","","","Percent of Total Billed Charges","neg_dollar:$483.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","483.00","930.00",""
"US SALINE INFUSED SONOHYSTEROGRAM","76831","CPT","70000222","CDM","402","RC","","Facility","Outpatient","","","803","642.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","803.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","690.58","86","","","Percent of Total Billed Charges","neg_dollar:$690.58","562.09","70","","","Percent of Total Billed Charges","neg_dollar:$562.09","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","471.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$471.76;102% of Medicaid interim rate","602.25","75","","","Percent of Total Billed Charges","neg_dollar:$602.25","690.58","86","","","Percent of Total Billed Charges","neg_dollar:$690.58","562.09","70","","","Percent of Total Billed Charges","neg_dollar:$562.09","457.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$457.71;103.5% of Medicaid interim rate","803.00","150","","","Percent of Total Billed Charges","neg_dollar:$1241.47;150% of Medicaid interim rate","642.40","80","","","Percent of Total Billed Charges","neg_dollar:$642.40;Percent of Total Billed Charges","","","","803.00","Fee Schedule","","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","417.56","52","","","Percent of Total Billed Charges","neg_dollar:$417.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","417.00","803.00",""
"US EXAM PELVIC COMP TRANSABDOMINAL","76856","CPT","70000223","CDM","402","RC","","Facility","Outpatient","","","613","490.40","613.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","318.76","52","","","Percent of Total Billed Charges","neg_dollar:$318.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","613.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","318.76","52","","","Percent of Total Billed Charges","neg_dollar:$318.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","318.76","52","","","Percent of Total Billed Charges","neg_dollar:$318.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","318.76","52","","","Percent of Total Billed Charges","neg_dollar:$318.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","527.18","86","","","Percent of Total Billed Charges","neg_dollar:$527.18","429.09","70","","","Percent of Total Billed Charges","neg_dollar:$429.09","318.76","52","","","Percent of Total Billed Charges","neg_dollar:$318.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","360.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$360.13;102% of Medicaid interim rate","459.75","75","","","Percent of Total Billed Charges","neg_dollar:$459.75","527.18","86","","","Percent of Total Billed Charges","neg_dollar:$527.18","429.09","70","","","Percent of Total Billed Charges","neg_dollar:$429.09","349.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$349.40;103.5% of Medicaid interim rate","613.00","150","","","Percent of Total Billed Charges","neg_dollar:$947.72;150% of Medicaid interim rate","490.40","80","","","Percent of Total Billed Charges","neg_dollar:$490.40;Percent of Total Billed Charges","","","","431.00","Fee Schedule","","318.76","52","","","Percent of Total Billed Charges","neg_dollar:$318.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","318.76","52","","","Percent of Total Billed Charges","neg_dollar:$318.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","318.00","613.00",""
"US EXAM PELVIC LTD TRANSABDOMINAL","76857","CPT","70000373","CDM","402","RC","","Facility","Outpatient","","","546","436.80","546.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","283.92","52","","","Percent of Total Billed Charges","neg_dollar:$283.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","546.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","283.92","52","","","Percent of Total Billed Charges","neg_dollar:$283.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","283.92","52","","","Percent of Total Billed Charges","neg_dollar:$283.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","283.92","52","","","Percent of Total Billed Charges","neg_dollar:$283.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","469.56","86","","","Percent of Total Billed Charges","neg_dollar:$469.56","382.20","70","","","Percent of Total Billed Charges","neg_dollar:$382.20","283.92","52","","","Percent of Total Billed Charges","neg_dollar:$283.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","320.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$320.77;102% of Medicaid interim rate","409.50","75","","","Percent of Total Billed Charges","neg_dollar:$409.50","469.56","86","","","Percent of Total Billed Charges","neg_dollar:$469.56","382.20","70","","","Percent of Total Billed Charges","neg_dollar:$382.20","311.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$311.21;103.5% of Medicaid interim rate","546.00","150","","","Percent of Total Billed Charges","neg_dollar:$844.14;150% of Medicaid interim rate","436.80","80","","","Percent of Total Billed Charges","neg_dollar:$436.80;Percent of Total Billed Charges","","","","433.00","Fee Schedule","","283.92","52","","","Percent of Total Billed Charges","neg_dollar:$283.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","283.92","52","","","Percent of Total Billed Charges","neg_dollar:$283.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","283.00","546.00",""
"US SCROTUM AND CONTENTS","76870","CPT","70000299","CDM","402","RC","","Facility","Outpatient","","","885","708.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","761.10","86","","","Percent of Total Billed Charges","neg_dollar:$761.10","619.50","70","","","Percent of Total Billed Charges","neg_dollar:$619.50","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","519.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$519.93;102% of Medicaid interim rate","663.75","75","","","Percent of Total Billed Charges","neg_dollar:$663.75","761.10","86","","","Percent of Total Billed Charges","neg_dollar:$761.10","619.50","70","","","Percent of Total Billed Charges","neg_dollar:$619.50","504.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$504.44;103.5% of Medicaid interim rate","885.00","150","","","Percent of Total Billed Charges","neg_dollar:$1368.25;150% of Medicaid interim rate","708.00","80","","","Percent of Total Billed Charges","neg_dollar:$708;Percent of Total Billed Charges","","","","607.00","Fee Schedule","","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","460.00","885.00",""
"US XTR NON-VASC COMPLETE","76881","CPT","70000300","CDM","402","RC","","Facility","Outpatient","","","665","532.00","665.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","665.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","571.90","86","","","Percent of Total Billed Charges","neg_dollar:$571.90","465.49","70","","","Percent of Total Billed Charges","neg_dollar:$465.49","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","390.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$390.68;102% of Medicaid interim rate","498.75","75","","","Percent of Total Billed Charges","neg_dollar:$498.75","571.90","86","","","Percent of Total Billed Charges","neg_dollar:$571.90","465.49","70","","","Percent of Total Billed Charges","neg_dollar:$465.49","379.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$379.04;103.5% of Medicaid interim rate","665.00","150","","","Percent of Total Billed Charges","neg_dollar:$1028.12;150% of Medicaid interim rate","532.00","80","","","Percent of Total Billed Charges","neg_dollar:$532;Percent of Total Billed Charges","","","","665.00","Fee Schedule","","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","345.00","665.00",""
"US XTR NON-VASC LTD","76882","CPT","70000301","CDM","402","RC","","Facility","Outpatient","","","646","516.80","646.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","646.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","555.56","86","","","Percent of Total Billed Charges","neg_dollar:$555.56","452.20","70","","","Percent of Total Billed Charges","neg_dollar:$452.20","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","379.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$379.52;102% of Medicaid interim rate","484.50","75","","","Percent of Total Billed Charges","neg_dollar:$484.50","555.56","86","","","Percent of Total Billed Charges","neg_dollar:$555.56","452.20","70","","","Percent of Total Billed Charges","neg_dollar:$452.20","368.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$368.21;103.5% of Medicaid interim rate","646.00","150","","","Percent of Total Billed Charges","neg_dollar:$998.74;150% of Medicaid interim rate","516.80","80","","","Percent of Total Billed Charges","neg_dollar:$516.80;Percent of Total Billed Charges","","","","646.00","Fee Schedule","","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","335.92","52","","","Percent of Total Billed Charges","neg_dollar:$335.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","335.00","646.00",""
"US INFANT HIPS W MANIPULATION","76885","CPT","70000225","CDM","402","RC","","Facility","Outpatient","","","608","486.40","608.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","608.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","522.88","86","","","Percent of Total Billed Charges","neg_dollar:$522.88","425.59","70","","","Percent of Total Billed Charges","neg_dollar:$425.59","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","357.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$357.19;102% of Medicaid interim rate","456.00","75","","","Percent of Total Billed Charges","neg_dollar:$456","522.88","86","","","Percent of Total Billed Charges","neg_dollar:$522.88","425.59","70","","","Percent of Total Billed Charges","neg_dollar:$425.59","346.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$346.55;103.5% of Medicaid interim rate","608.00","150","","","Percent of Total Billed Charges","neg_dollar:$939.99;150% of Medicaid interim rate","486.40","80","","","Percent of Total Billed Charges","neg_dollar:$486.40;Percent of Total Billed Charges","","","","608.00","Fee Schedule","","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","316.00","608.00",""
"US INFANT HIPS WO MANIPULATION","76886","CPT","70000302","CDM","402","RC","","Facility","Outpatient","","","470","376.00","470.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","244.40","52","","","Percent of Total Billed Charges","neg_dollar:$244.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","470.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","244.40","52","","","Percent of Total Billed Charges","neg_dollar:$244.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","244.40","52","","","Percent of Total Billed Charges","neg_dollar:$244.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","244.40","52","","","Percent of Total Billed Charges","neg_dollar:$244.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","404.20","86","","","Percent of Total Billed Charges","neg_dollar:$404.20","329.00","70","","","Percent of Total Billed Charges","neg_dollar:$329","244.40","52","","","Percent of Total Billed Charges","neg_dollar:$244.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","276.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$276.12;102% of Medicaid interim rate","352.50","75","","","Percent of Total Billed Charges","neg_dollar:$352.50","404.20","86","","","Percent of Total Billed Charges","neg_dollar:$404.20","329.00","70","","","Percent of Total Billed Charges","neg_dollar:$329","267.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$267.90;103.5% of Medicaid interim rate","470.00","150","","","Percent of Total Billed Charges","neg_dollar:$726.64;150% of Medicaid interim rate","376.00","80","","","Percent of Total Billed Charges","neg_dollar:$376;Percent of Total Billed Charges","","","","470.00","Fee Schedule","","244.40","52","","","Percent of Total Billed Charges","neg_dollar:$244.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","244.40","52","","","Percent of Total Billed Charges","neg_dollar:$244.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","244.00","470.00",""
"US GUIDANCE VASCULAR ACCESS","76937","CPT","70000375","CDM","402","RC","","Facility","Outpatient","","","457","365.60","457.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","457.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","393.02","86","","","Percent of Total Billed Charges","neg_dollar:$393.02","319.90","70","","","Percent of Total Billed Charges","neg_dollar:$319.90","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","268.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$268.48;102% of Medicaid interim rate","342.75","75","","","Percent of Total Billed Charges","neg_dollar:$342.75","393.02","86","","","Percent of Total Billed Charges","neg_dollar:$393.02","319.90","70","","","Percent of Total Billed Charges","neg_dollar:$319.90","260.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$260.48;103.5% of Medicaid interim rate","457.00","150","","","Percent of Total Billed Charges","neg_dollar:$706.54;150% of Medicaid interim rate","365.60","80","","","Percent of Total Billed Charges","neg_dollar:$365.60;Percent of Total Billed Charges","","","","457.00","Fee Schedule","","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","237.00","457.00",""
"US GUIDED NEEDLE PLACEMENT","76942","CPT","70000303","CDM","402","RC","","Facility","Outpatient","","","923","738.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","479.96","52","","","Percent of Total Billed Charges","neg_dollar:$479.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","479.96","52","","","Percent of Total Billed Charges","neg_dollar:$479.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","479.96","52","","","Percent of Total Billed Charges","neg_dollar:$479.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","479.96","52","","","Percent of Total Billed Charges","neg_dollar:$479.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","793.78","86","","","Percent of Total Billed Charges","neg_dollar:$793.78","646.09","70","","","Percent of Total Billed Charges","neg_dollar:$646.09","479.96","52","","","Percent of Total Billed Charges","neg_dollar:$479.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","542.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$542.26;102% of Medicaid interim rate","692.25","75","","","Percent of Total Billed Charges","neg_dollar:$692.25","793.78","86","","","Percent of Total Billed Charges","neg_dollar:$793.78","646.09","70","","","Percent of Total Billed Charges","neg_dollar:$646.09","526.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$526.10;103.5% of Medicaid interim rate","923.00","150","","","Percent of Total Billed Charges","neg_dollar:$1427;150% of Medicaid interim rate","738.40","80","","","Percent of Total Billed Charges","neg_dollar:$738.40;Percent of Total Billed Charges","","","","649.00","Fee Schedule","","479.96","52","","","Percent of Total Billed Charges","neg_dollar:$479.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","479.96","52","","","Percent of Total Billed Charges","neg_dollar:$479.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","479.00","923.00",""
"US GUIDANCE INTRAOPERATIVE","76998","CPT","70000376","CDM","402","RC","","Facility","Outpatient","","","545","436.00","545.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","283.40","52","","","Percent of Total Billed Charges","neg_dollar:$283.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","545.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","283.40","52","","","Percent of Total Billed Charges","neg_dollar:$283.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","283.40","52","","","Percent of Total Billed Charges","neg_dollar:$283.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","283.40","52","","","Percent of Total Billed Charges","neg_dollar:$283.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","468.70","86","","","Percent of Total Billed Charges","neg_dollar:$468.70","381.50","70","","","Percent of Total Billed Charges","neg_dollar:$381.50","283.40","52","","","Percent of Total Billed Charges","neg_dollar:$283.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","320.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$320.18;102% of Medicaid interim rate","408.75","75","","","Percent of Total Billed Charges","neg_dollar:$408.75","468.70","86","","","Percent of Total Billed Charges","neg_dollar:$468.70","381.50","70","","","Percent of Total Billed Charges","neg_dollar:$381.50","310.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$310.65;103.5% of Medicaid interim rate","545.00","150","","","Percent of Total Billed Charges","neg_dollar:$842.59;150% of Medicaid interim rate","436.00","80","","","Percent of Total Billed Charges","neg_dollar:$436;Percent of Total Billed Charges","","","","545.00","Fee Schedule","","283.40","52","","","Percent of Total Billed Charges","neg_dollar:$283.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","283.40","52","","","Percent of Total Billed Charges","neg_dollar:$283.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","283.00","545.00",""
"FLUOROGUIDE FOR VENOUS DEVICE","77001","CPT","70000477","CDM","320","RC","","Facility","Outpatient","","","755","604.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","755.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","649.30","86","","","Percent of Total Billed Charges","neg_dollar:$649.30","528.50","70","","","Percent of Total Billed Charges","neg_dollar:$528.50","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","443.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$443.56;102% of Medicaid interim rate","566.25","75","","","Percent of Total Billed Charges","neg_dollar:$566.25","649.30","86","","","Percent of Total Billed Charges","neg_dollar:$649.30","528.50","70","","","Percent of Total Billed Charges","neg_dollar:$528.50","430.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$430.34;103.5% of Medicaid interim rate","755.00","150","","","Percent of Total Billed Charges","neg_dollar:$1167.26;150% of Medicaid interim rate","604.00","80","","","Percent of Total Billed Charges","neg_dollar:$604;Percent of Total Billed Charges","","","","755.00","Fee Schedule","","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","392.60","52","","","Percent of Total Billed Charges","neg_dollar:$392.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","392.00","755.00",""
"FLUOROGUIDANCE FOR NEEDLE PLC","77002","CPT","70000425","CDM","320","RC","","Facility","Outpatient","","","878","702.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","515.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$515.82;102% of Medicaid interim rate","658.50","75","","","Percent of Total Billed Charges","neg_dollar:$658.50","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","500.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$500.46;103.5% of Medicaid interim rate","878.00","150","","","Percent of Total Billed Charges","neg_dollar:$1357.43;150% of Medicaid interim rate","702.40","80","","","Percent of Total Billed Charges","neg_dollar:$702.40;Percent of Total Billed Charges","","","","438.00","Fee Schedule","","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","438.00","878.00",""
"FLUOROGUIDANCE FOR SPINE INJECT","77003","CPT","70000377","CDM","320","RC","","Facility","Outpatient","","","878","702.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","515.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$515.82;102% of Medicaid interim rate","658.50","75","","","Percent of Total Billed Charges","neg_dollar:$658.50","755.08","86","","","Percent of Total Billed Charges","neg_dollar:$755.08","614.59","70","","","Percent of Total Billed Charges","neg_dollar:$614.59","500.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$500.46;103.5% of Medicaid interim rate","878.00","150","","","Percent of Total Billed Charges","neg_dollar:$1357.43;150% of Medicaid interim rate","702.40","80","","","Percent of Total Billed Charges","neg_dollar:$702.40;Percent of Total Billed Charges","","","","878.00","Fee Schedule","","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.56","52","","","Percent of Total Billed Charges","neg_dollar:$456.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","456.00","878.00",""
"CT GUIDANCE NEEDLE PLACEMENT","77012","CPT","70000234","CDM","350","RC","","Facility","Outpatient","","","1216","972.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","632.32","52","","","Percent of Total Billed Charges","neg_dollar:$632.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","632.32","52","","","Percent of Total Billed Charges","neg_dollar:$632.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","632.32","52","","","Percent of Total Billed Charges","neg_dollar:$632.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","632.32","52","","","Percent of Total Billed Charges","neg_dollar:$632.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1045.76","86","","","Percent of Total Billed Charges","neg_dollar:$1045.76","851.19","70","","","Percent of Total Billed Charges","neg_dollar:$851.19","632.32","52","","","Percent of Total Billed Charges","neg_dollar:$632.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","714.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$714.39;102% of Medicaid interim rate","912.00","75","","","Percent of Total Billed Charges","neg_dollar:$912","1045.76","86","","","Percent of Total Billed Charges","neg_dollar:$1045.76","851.19","70","","","Percent of Total Billed Charges","neg_dollar:$851.19","693.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$693.11;103.5% of Medicaid interim rate","1216.00","150","","","Percent of Total Billed Charges","neg_dollar:$1879.99;150% of Medicaid interim rate","972.80","80","","","Percent of Total Billed Charges","neg_dollar:$972.80;Percent of Total Billed Charges","","","","1216.00","Fee Schedule","","632.32","52","","","Percent of Total Billed Charges","neg_dollar:$632.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","632.32","52","","","Percent of Total Billed Charges","neg_dollar:$632.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","632.00","1216.00",""
"MM X-RAY OF MAMMARY DUCT","77053","CPT","70000384","CDM","320","RC","","Facility","Outpatient","","","391","312.80","391.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","391.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","336.26","86","","","Percent of Total Billed Charges","neg_dollar:$336.26","273.70","70","","","Percent of Total Billed Charges","neg_dollar:$273.70","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","229.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$229.71;102% of Medicaid interim rate","293.25","75","","","Percent of Total Billed Charges","neg_dollar:$293.25","336.26","86","","","Percent of Total Billed Charges","neg_dollar:$336.26","273.70","70","","","Percent of Total Billed Charges","neg_dollar:$273.70","222.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$222.86;103.5% of Medicaid interim rate","391.00","150","","","Percent of Total Billed Charges","neg_dollar:$604.50;150% of Medicaid interim rate","312.80","80","","","Percent of Total Billed Charges","neg_dollar:$312.80;Percent of Total Billed Charges","","","","391.00","Fee Schedule","","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","203.00","391.00",""
"BREAST TOMOSYNTHESIS DIG DX UNIL","77061","CPT","70000734","CDM","401","RC","","Facility","Outpatient","","","46","36.80","46.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","46.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","39.56","86","","","Percent of Total Billed Charges","neg_dollar:$39.56","32.19","70","","","Percent of Total Billed Charges","neg_dollar:$32.19","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","27.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.02;102% of Medicaid interim rate","34.50","75","","","Percent of Total Billed Charges","neg_dollar:$34.50","39.56","86","","","Percent of Total Billed Charges","neg_dollar:$39.56","32.19","70","","","Percent of Total Billed Charges","neg_dollar:$32.19","26.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.22;103.5% of Medicaid interim rate","46.00","150","","","Percent of Total Billed Charges","neg_dollar:$71.11;150% of Medicaid interim rate","36.80","80","","","Percent of Total Billed Charges","neg_dollar:$36.80;Percent of Total Billed Charges","","","","46.00","Fee Schedule","","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.00","46.00",""
"BREAST TOMOSYNTHESIS DIG DX BILAT","77062","CPT","70000736","CDM","401","RC","","Facility","Outpatient","","","65","52.00","65.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","65.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","55.90","86","","","Percent of Total Billed Charges","neg_dollar:$55.90","45.50","70","","","Percent of Total Billed Charges","neg_dollar:$45.50","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","38.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$38.18;102% of Medicaid interim rate","48.75","75","","","Percent of Total Billed Charges","neg_dollar:$48.75","55.90","86","","","Percent of Total Billed Charges","neg_dollar:$55.90","45.50","70","","","Percent of Total Billed Charges","neg_dollar:$45.50","37.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.05;103.5% of Medicaid interim rate","65.00","150","","","Percent of Total Billed Charges","neg_dollar:$100.49;150% of Medicaid interim rate","52.00","80","","","Percent of Total Billed Charges","neg_dollar:$52;Percent of Total Billed Charges","","","","65.00","Fee Schedule","","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","65.00",""
"BREAST TOMOSYNTHESIS DIG SCREEN BILAT","77063","CPT","70000722","CDM","403","RC","","Facility","Outpatient","","","65","52.00","65.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","65.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","55.90","86","","","Percent of Total Billed Charges","neg_dollar:$55.90","45.50","70","","","Percent of Total Billed Charges","neg_dollar:$45.50","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","38.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$38.18;102% of Medicaid interim rate","48.75","75","","","Percent of Total Billed Charges","neg_dollar:$48.75","55.90","86","","","Percent of Total Billed Charges","neg_dollar:$55.90","45.50","70","","","Percent of Total Billed Charges","neg_dollar:$45.50","37.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.05;103.5% of Medicaid interim rate","65.00","150","","","Percent of Total Billed Charges","neg_dollar:$100.49;150% of Medicaid interim rate","52.00","80","","","Percent of Total Billed Charges","neg_dollar:$52;Percent of Total Billed Charges","","","","65.00","Fee Schedule","","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","65.00",""
"BREAST TOMOSYNTHESIS DIG SCREEN UNIL","77063","CPT","70000816","CDM","403","RC","52","Facility","Outpatient","","","46","36.80","46.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","46.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","39.56","86","","","Percent of Total Billed Charges","neg_dollar:$39.56","32.19","70","","","Percent of Total Billed Charges","neg_dollar:$32.19","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","27.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.02;102% of Medicaid interim rate","34.50","75","","","Percent of Total Billed Charges","neg_dollar:$34.50","39.56","86","","","Percent of Total Billed Charges","neg_dollar:$39.56","32.19","70","","","Percent of Total Billed Charges","neg_dollar:$32.19","26.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.22;103.5% of Medicaid interim rate","46.00","150","","","Percent of Total Billed Charges","neg_dollar:$71.11;150% of Medicaid interim rate","36.80","80","","","Percent of Total Billed Charges","neg_dollar:$36.80;Percent of Total Billed Charges","","","","46.00","Fee Schedule","","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.00","46.00",""
"DX MAMMO INCL CAD UNIL","77065","CPT","70000787","CDM","401","RC","","Facility","Outpatient","","","563","450.40","563.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","292.76","52","","","Percent of Total Billed Charges","neg_dollar:$292.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","563.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","292.76","52","","","Percent of Total Billed Charges","neg_dollar:$292.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","292.76","52","","","Percent of Total Billed Charges","neg_dollar:$292.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","292.76","52","","","Percent of Total Billed Charges","neg_dollar:$292.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","484.18","86","","","Percent of Total Billed Charges","neg_dollar:$484.18","394.09","70","","","Percent of Total Billed Charges","neg_dollar:$394.09","292.76","52","","","Percent of Total Billed Charges","neg_dollar:$292.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","330.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$330.76;102% of Medicaid interim rate","422.25","75","","","Percent of Total Billed Charges","neg_dollar:$422.25","484.18","86","","","Percent of Total Billed Charges","neg_dollar:$484.18","394.09","70","","","Percent of Total Billed Charges","neg_dollar:$394.09","320.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$320.90;103.5% of Medicaid interim rate","563.00","150","","","Percent of Total Billed Charges","neg_dollar:$870.42;150% of Medicaid interim rate","450.40","80","","","Percent of Total Billed Charges","neg_dollar:$450.40;Percent of Total Billed Charges","","","","563.00","Fee Schedule","","292.76","52","","","Percent of Total Billed Charges","neg_dollar:$292.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","292.76","52","","","Percent of Total Billed Charges","neg_dollar:$292.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","292.00","563.00",""
"DX MAMMO INCL CAD BILAT","77066","CPT","70000788","CDM","401","RC","","Facility","Outpatient","","","665","532.00","665.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","665.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","571.90","86","","","Percent of Total Billed Charges","neg_dollar:$571.90","465.49","70","","","Percent of Total Billed Charges","neg_dollar:$465.49","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","390.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$390.68;102% of Medicaid interim rate","498.75","75","","","Percent of Total Billed Charges","neg_dollar:$498.75","571.90","86","","","Percent of Total Billed Charges","neg_dollar:$571.90","465.49","70","","","Percent of Total Billed Charges","neg_dollar:$465.49","379.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$379.04;103.5% of Medicaid interim rate","665.00","150","","","Percent of Total Billed Charges","neg_dollar:$1028.12;150% of Medicaid interim rate","532.00","80","","","Percent of Total Billed Charges","neg_dollar:$532;Percent of Total Billed Charges","","","","444.00","Fee Schedule","","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","345.80","52","","","Percent of Total Billed Charges","neg_dollar:$345.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","345.00","665.00",""
"SCR MAMMO INCL CAD BILAT","77067","CPT","70000789","CDM","403","RC","","Facility","Outpatient","","","609","487.20","609.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","316.68","52","","","Percent of Total Billed Charges","neg_dollar:$316.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","609.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","316.68","52","","","Percent of Total Billed Charges","neg_dollar:$316.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","316.68","52","","","Percent of Total Billed Charges","neg_dollar:$316.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","316.68","52","","","Percent of Total Billed Charges","neg_dollar:$316.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","523.74","86","","","Percent of Total Billed Charges","neg_dollar:$523.74","426.29","70","","","Percent of Total Billed Charges","neg_dollar:$426.29","316.68","52","","","Percent of Total Billed Charges","neg_dollar:$316.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","357.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$357.78;102% of Medicaid interim rate","456.75","75","","","Percent of Total Billed Charges","neg_dollar:$456.75","523.74","86","","","Percent of Total Billed Charges","neg_dollar:$523.74","426.29","70","","","Percent of Total Billed Charges","neg_dollar:$426.29","347.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$347.13;103.5% of Medicaid interim rate","609.00","150","","","Percent of Total Billed Charges","neg_dollar:$941.54;150% of Medicaid interim rate","487.20","80","","","Percent of Total Billed Charges","neg_dollar:$487.20;Percent of Total Billed Charges","","","","609.00","Fee Schedule","","316.68","52","","","Percent of Total Billed Charges","neg_dollar:$316.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","316.68","52","","","Percent of Total Billed Charges","neg_dollar:$316.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","316.00","609.00",""
"SCR MAMMO INCL CAD UNIL","77067","CPT","70000790","CDM","403","RC","52","Facility","Outpatient","","","500","400.00","500.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;101% Medicare Outpatient Cost to Charge Ratio of 52%","500.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;102% Medicare Outpatient Cost to Charge Ratio of 52%","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;102% Medicare Outpatient Cost to Charge Ratio of 52%","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;102% Medicare Outpatient Cost to Charge Ratio of 52%","430.00","86","","","Percent of Total Billed Charges","neg_dollar:$430","350.00","70","","","Percent of Total Billed Charges","neg_dollar:$350","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;105% Medicare Outpatient Cost to Charge Ratio of 52%","293.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$293.74;102% of Medicaid interim rate","375.00","75","","","Percent of Total Billed Charges","neg_dollar:$375","430.00","86","","","Percent of Total Billed Charges","neg_dollar:$430","350.00","70","","","Percent of Total Billed Charges","neg_dollar:$350","285.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$285;103.5% of Medicaid interim rate","500.00","150","","","Percent of Total Billed Charges","neg_dollar:$773.02;150% of Medicaid interim rate","400.00","80","","","Percent of Total Billed Charges","neg_dollar:$400;Percent of Total Billed Charges","","","","500.00","Fee Schedule","","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;100% Medicare Outpatient Cost to Charge Ratio of 52%","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;100% Medicare Outpatient Cost to Charge Ratio of 52%","260.00","500.00",""
"STRESS VIEW ANY JOINT","77071","CPT","70000238","CDM","320","RC","","Facility","Outpatient","","","214","171.20","214.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","214.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.04","86","","","Percent of Total Billed Charges","neg_dollar:$184.04","149.79","70","","","Percent of Total Billed Charges","neg_dollar:$149.79","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","125.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$125.72;102% of Medicaid interim rate","160.50","75","","","Percent of Total Billed Charges","neg_dollar:$160.50","184.04","86","","","Percent of Total Billed Charges","neg_dollar:$184.04","149.79","70","","","Percent of Total Billed Charges","neg_dollar:$149.79","121.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$121.97;103.5% of Medicaid interim rate","214.00","150","","","Percent of Total Billed Charges","neg_dollar:$330.85;150% of Medicaid interim rate","171.20","80","","","Percent of Total Billed Charges","neg_dollar:$171.20;Percent of Total Billed Charges","","","","214.00","Fee Schedule","","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","111.28","52","","","Percent of Total Billed Charges","neg_dollar:$111.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","111.00","214.00",""
"BONE AGE STUDIES","77072","CPT","70000239","CDM","320","RC","","Facility","Outpatient","","","318","254.40","318.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","318.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","273.48","86","","","Percent of Total Billed Charges","neg_dollar:$273.48","222.60","70","","","Percent of Total Billed Charges","neg_dollar:$222.60","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","186.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$186.82;102% of Medicaid interim rate","238.50","75","","","Percent of Total Billed Charges","neg_dollar:$238.50","273.48","86","","","Percent of Total Billed Charges","neg_dollar:$273.48","222.60","70","","","Percent of Total Billed Charges","neg_dollar:$222.60","181.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$181.26;103.5% of Medicaid interim rate","318.00","150","","","Percent of Total Billed Charges","neg_dollar:$491.64;150% of Medicaid interim rate","254.40","80","","","Percent of Total Billed Charges","neg_dollar:$254.40;Percent of Total Billed Charges","","","","318.00","Fee Schedule","","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","165.00","318.00",""
"BONE LENGTH STUDIES","77073","CPT","70000240","CDM","320","RC","","Facility","Outpatient","","","347","277.60","347.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","347.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","298.42","86","","","Percent of Total Billed Charges","neg_dollar:$298.42","242.89","70","","","Percent of Total Billed Charges","neg_dollar:$242.89","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","203.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$203.86;102% of Medicaid interim rate","260.25","75","","","Percent of Total Billed Charges","neg_dollar:$260.25","298.42","86","","","Percent of Total Billed Charges","neg_dollar:$298.42","242.89","70","","","Percent of Total Billed Charges","neg_dollar:$242.89","197.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$197.79;103.5% of Medicaid interim rate","347.00","150","","","Percent of Total Billed Charges","neg_dollar:$536.47;150% of Medicaid interim rate","277.60","80","","","Percent of Total Billed Charges","neg_dollar:$277.60;Percent of Total Billed Charges","","","","347.00","Fee Schedule","","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","180.00","347.00",""
"BONE SURVEY COMPLETE","77075","CPT","70000241","CDM","320","RC","","Facility","Outpatient","","","1181","944.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","614.12","52","","","Percent of Total Billed Charges","neg_dollar:$614.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","614.12","52","","","Percent of Total Billed Charges","neg_dollar:$614.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","614.12","52","","","Percent of Total Billed Charges","neg_dollar:$614.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","614.12","52","","","Percent of Total Billed Charges","neg_dollar:$614.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","1015.66","86","","","Percent of Total Billed Charges","neg_dollar:$1015.66","826.69","70","","","Percent of Total Billed Charges","neg_dollar:$826.69","614.12","52","","","Percent of Total Billed Charges","neg_dollar:$614.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","693.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$693.83;102% of Medicaid interim rate","885.75","75","","","Percent of Total Billed Charges","neg_dollar:$885.75","1015.66","86","","","Percent of Total Billed Charges","neg_dollar:$1015.66","826.69","70","","","Percent of Total Billed Charges","neg_dollar:$826.69","673.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$673.17;103.5% of Medicaid interim rate","1181.00","150","","","Percent of Total Billed Charges","neg_dollar:$1825.88;150% of Medicaid interim rate","944.80","80","","","Percent of Total Billed Charges","neg_dollar:$944.80;Percent of Total Billed Charges","","","","1181.00","Fee Schedule","","614.12","52","","","Percent of Total Billed Charges","neg_dollar:$614.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","614.12","52","","","Percent of Total Billed Charges","neg_dollar:$614.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","614.00","1181.00",""
"BONE SURVEY INFANT","77076","CPT","70000242","CDM","320","RC","","Facility","Outpatient","","","560","448.00","560.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","291.20","52","","","Percent of Total Billed Charges","neg_dollar:$291.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","560.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","291.20","52","","","Percent of Total Billed Charges","neg_dollar:$291.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","291.20","52","","","Percent of Total Billed Charges","neg_dollar:$291.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","291.20","52","","","Percent of Total Billed Charges","neg_dollar:$291.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","481.59","86","","","Percent of Total Billed Charges","neg_dollar:$481.59","392.00","70","","","Percent of Total Billed Charges","neg_dollar:$392","291.20","52","","","Percent of Total Billed Charges","neg_dollar:$291.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","328.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$328.99;102% of Medicaid interim rate","420.00","75","","","Percent of Total Billed Charges","neg_dollar:$420","481.59","86","","","Percent of Total Billed Charges","neg_dollar:$481.59","392.00","70","","","Percent of Total Billed Charges","neg_dollar:$392","319.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$319.20;103.5% of Medicaid interim rate","560.00","150","","","Percent of Total Billed Charges","neg_dollar:$865.78;150% of Medicaid interim rate","448.00","80","","","Percent of Total Billed Charges","neg_dollar:$448;Percent of Total Billed Charges","","","","560.00","Fee Schedule","","291.20","52","","","Percent of Total Billed Charges","neg_dollar:$291.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","291.20","52","","","Percent of Total Billed Charges","neg_dollar:$291.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","291.00","560.00",""
"DXA BONE DENSITY AXIAL","77080","CPT","70000388","CDM","320","RC","","Facility","Outpatient","","","774","619.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","774.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","665.64","86","","","Percent of Total Billed Charges","neg_dollar:$665.64","541.80","70","","","Percent of Total Billed Charges","neg_dollar:$541.80","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","454.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$454.72;102% of Medicaid interim rate","580.50","75","","","Percent of Total Billed Charges","neg_dollar:$580.50","665.64","86","","","Percent of Total Billed Charges","neg_dollar:$665.64","541.80","70","","","Percent of Total Billed Charges","neg_dollar:$541.80","441.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$441.17;103.5% of Medicaid interim rate","774.00","150","","","Percent of Total Billed Charges","neg_dollar:$1196.64;150% of Medicaid interim rate","619.20","80","","","Percent of Total Billed Charges","neg_dollar:$619.20;Percent of Total Billed Charges","","","","614.00","Fee Schedule","","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","402.00","774.00",""
"MM DXA BONE DENSITY/PERIPHERAL 1+ SITES","77081","CPT","70000611","CDM","320","RC","","Facility","Outpatient","","","660","528.00","660.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","343.20","52","","","Percent of Total Billed Charges","neg_dollar:$343.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","660.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","343.20","52","","","Percent of Total Billed Charges","neg_dollar:$343.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","343.20","52","","","Percent of Total Billed Charges","neg_dollar:$343.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","343.20","52","","","Percent of Total Billed Charges","neg_dollar:$343.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","567.60","86","","","Percent of Total Billed Charges","neg_dollar:$567.60","461.99","70","","","Percent of Total Billed Charges","neg_dollar:$461.99","343.20","52","","","Percent of Total Billed Charges","neg_dollar:$343.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","387.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$387.74;102% of Medicaid interim rate","495.00","75","","","Percent of Total Billed Charges","neg_dollar:$495","567.60","86","","","Percent of Total Billed Charges","neg_dollar:$567.60","461.99","70","","","Percent of Total Billed Charges","neg_dollar:$461.99","376.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$376.20;103.5% of Medicaid interim rate","660.00","150","","","Percent of Total Billed Charges","neg_dollar:$1020.39;150% of Medicaid interim rate","528.00","80","","","Percent of Total Billed Charges","neg_dollar:$528;Percent of Total Billed Charges","","","","660.00","Fee Schedule","","343.20","52","","","Percent of Total Billed Charges","neg_dollar:$343.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","343.20","52","","","Percent of Total Billed Charges","neg_dollar:$343.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","343.00","660.00",""
"THYROID UPTAKE MEASUREMENT","78012","CPT","70000670","CDM","341","RC","","Facility","Outpatient","","","1012","809.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","870.31","86","","","Percent of Total Billed Charges","neg_dollar:$870.31","708.40","70","","","Percent of Total Billed Charges","neg_dollar:$708.40","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","594.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$594.54;102% of Medicaid interim rate","759.00","75","","","Percent of Total Billed Charges","neg_dollar:$759","870.31","86","","","Percent of Total Billed Charges","neg_dollar:$870.31","708.40","70","","","Percent of Total Billed Charges","neg_dollar:$708.40","576.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$576.83;103.5% of Medicaid interim rate","1012.00","150","","","Percent of Total Billed Charges","neg_dollar:$1564.60;150% of Medicaid interim rate","809.60","80","","","Percent of Total Billed Charges","neg_dollar:$809.60;Percent of Total Billed Charges","","","","1012.00","Fee Schedule","","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","526.24","52","","","Percent of Total Billed Charges","neg_dollar:$526.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","526.00","1012.00",""
"THYROID IMAG W/BLOOD FLOW","78013","CPT","70000671","CDM","341","RC","","Facility","Outpatient","","","896","716.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","465.92","52","","","Percent of Total Billed Charges","neg_dollar:$465.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","465.92","52","","","Percent of Total Billed Charges","neg_dollar:$465.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","465.92","52","","","Percent of Total Billed Charges","neg_dollar:$465.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","465.92","52","","","Percent of Total Billed Charges","neg_dollar:$465.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","770.56","86","","","Percent of Total Billed Charges","neg_dollar:$770.56","627.19","70","","","Percent of Total Billed Charges","neg_dollar:$627.19","465.92","52","","","Percent of Total Billed Charges","neg_dollar:$465.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","526.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$526.39;102% of Medicaid interim rate","672.00","75","","","Percent of Total Billed Charges","neg_dollar:$672","770.56","86","","","Percent of Total Billed Charges","neg_dollar:$770.56","627.19","70","","","Percent of Total Billed Charges","neg_dollar:$627.19","510.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$510.71;103.5% of Medicaid interim rate","896.00","150","","","Percent of Total Billed Charges","neg_dollar:$1385.26;150% of Medicaid interim rate","716.80","80","","","Percent of Total Billed Charges","neg_dollar:$716.80;Percent of Total Billed Charges","","","","896.00","Fee Schedule","","465.92","52","","","Percent of Total Billed Charges","neg_dollar:$465.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","465.92","52","","","Percent of Total Billed Charges","neg_dollar:$465.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","465.00","896.00",""
"THYROID IMAG W/BLOOD FLOW SGL/MULT QUAN","78014","CPT","70000672","CDM","341","RC","","Facility","Outpatient","","","846","676.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","727.56","86","","","Percent of Total Billed Charges","neg_dollar:$727.56","592.19","70","","","Percent of Total Billed Charges","neg_dollar:$592.19","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","497.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$497.02;102% of Medicaid interim rate","634.50","75","","","Percent of Total Billed Charges","neg_dollar:$634.50","727.56","86","","","Percent of Total Billed Charges","neg_dollar:$727.56","592.19","70","","","Percent of Total Billed Charges","neg_dollar:$592.19","482.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$482.21;103.5% of Medicaid interim rate","846.00","150","","","Percent of Total Billed Charges","neg_dollar:$1307.95;150% of Medicaid interim rate","676.80","80","","","Percent of Total Billed Charges","neg_dollar:$676.80;Percent of Total Billed Charges","","","","846.00","Fee Schedule","","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","439.00","846.00",""
"NM LYMPH OR LYMPH NODE IMAGING","78195","CPT","70000249","CDM","341","RC","","Facility","Outpatient","","","2037","1629.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1059.24","52","","","Percent of Total Billed Charges","neg_dollar:$1059.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1059.24","52","","","Percent of Total Billed Charges","neg_dollar:$1059.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1059.24","52","","","Percent of Total Billed Charges","neg_dollar:$1059.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1059.24","52","","","Percent of Total Billed Charges","neg_dollar:$1059.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1751.82","86","","","Percent of Total Billed Charges","neg_dollar:$1751.82","1425.89","70","","","Percent of Total Billed Charges","neg_dollar:$1425.89","1059.24","52","","","Percent of Total Billed Charges","neg_dollar:$1059.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","1196.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$1196.73;102% of Medicaid interim rate","1527.75","75","","","Percent of Total Billed Charges","neg_dollar:$1527.75","1751.82","86","","","Percent of Total Billed Charges","neg_dollar:$1751.82","1425.89","70","","","Percent of Total Billed Charges","neg_dollar:$1425.89","1161.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$1161.09;103.5% of Medicaid interim rate","2037.00","150","","","Percent of Total Billed Charges","neg_dollar:$3149.30;150% of Medicaid interim rate","1629.60","80","","","Percent of Total Billed Charges","neg_dollar:$1629.60;Percent of Total Billed Charges","","","","2037.00","Fee Schedule","","1059.24","52","","","Percent of Total Billed Charges","neg_dollar:$1059.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1059.24","52","","","Percent of Total Billed Charges","neg_dollar:$1059.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2037.00",""
"NM LIVER SPLEEN STATIC","78215","CPT","70000251","CDM","341","RC","","Facility","Outpatient","","","1352","1081.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1162.72","86","","","Percent of Total Billed Charges","neg_dollar:$1162.72","946.40","70","","","Percent of Total Billed Charges","neg_dollar:$946.40","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","794.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$794.29;102% of Medicaid interim rate","1014.00","75","","","Percent of Total Billed Charges","neg_dollar:$1014","1162.72","86","","","Percent of Total Billed Charges","neg_dollar:$1162.72","946.40","70","","","Percent of Total Billed Charges","neg_dollar:$946.40","770.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$770.64;103.5% of Medicaid interim rate","1352.00","150","","","Percent of Total Billed Charges","neg_dollar:$2090.25;150% of Medicaid interim rate","1081.60","80","","","Percent of Total Billed Charges","neg_dollar:$1081.60;Percent of Total Billed Charges","","","","1352.00","Fee Schedule","","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","703.00","1352.00",""
"NM HEPATOBILIARY SYSTEM IMAGING","78226","CPT","70000590","CDM","341","RC","","Facility","Outpatient","","","1639","1311.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","852.28","52","","","Percent of Total Billed Charges","neg_dollar:$852.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","852.28","52","","","Percent of Total Billed Charges","neg_dollar:$852.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","852.28","52","","","Percent of Total Billed Charges","neg_dollar:$852.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","852.28","52","","","Percent of Total Billed Charges","neg_dollar:$852.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","1409.54","86","","","Percent of Total Billed Charges","neg_dollar:$1409.54","1147.30","70","","","Percent of Total Billed Charges","neg_dollar:$1147.30","852.28","52","","","Percent of Total Billed Charges","neg_dollar:$852.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","962.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$962.91;102% of Medicaid interim rate","1229.25","75","","","Percent of Total Billed Charges","neg_dollar:$1229.25","1409.54","86","","","Percent of Total Billed Charges","neg_dollar:$1409.54","1147.30","70","","","Percent of Total Billed Charges","neg_dollar:$1147.30","934.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$934.22;103.5% of Medicaid interim rate","1639.00","150","","","Percent of Total Billed Charges","neg_dollar:$2533.97;150% of Medicaid interim rate","1311.20","80","","","Percent of Total Billed Charges","neg_dollar:$1311.20;Percent of Total Billed Charges","","","","1639.00","Fee Schedule","","852.28","52","","","Percent of Total Billed Charges","neg_dollar:$852.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","852.28","52","","","Percent of Total Billed Charges","neg_dollar:$852.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1639.00",""
"NM HEPATOBIL SYST IMAGE W/DRUG","78227","CPT","70000591","CDM","341","RC","","Facility","Outpatient","","","2117","1693.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1100.84","52","","","Percent of Total Billed Charges","neg_dollar:$1100.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1100.84","52","","","Percent of Total Billed Charges","neg_dollar:$1100.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","1100.84","52","","","Percent of Total Billed Charges","neg_dollar:$1100.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","1100.84","52","","","Percent of Total Billed Charges","neg_dollar:$1100.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","1820.62","86","","","Percent of Total Billed Charges","neg_dollar:$1820.62","1481.89","70","","","Percent of Total Billed Charges","neg_dollar:$1481.89","1100.84","52","","","Percent of Total Billed Charges","neg_dollar:$1100.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","1243.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$1243.73;102% of Medicaid interim rate","1587.75","75","","","Percent of Total Billed Charges","neg_dollar:$1587.75","1820.62","86","","","Percent of Total Billed Charges","neg_dollar:$1820.62","1481.89","70","","","Percent of Total Billed Charges","neg_dollar:$1481.89","1206.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$1206.68;103.5% of Medicaid interim rate","2117.00","150","","","Percent of Total Billed Charges","neg_dollar:$3272.98;150% of Medicaid interim rate","1693.60","80","","","Percent of Total Billed Charges","neg_dollar:$1693.60;Percent of Total Billed Charges","","","","1369.00","Fee Schedule","","1100.84","52","","","Percent of Total Billed Charges","neg_dollar:$1100.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","1100.84","52","","","Percent of Total Billed Charges","neg_dollar:$1100.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2117.00",""
"NM GASTRIC EMPTYING STUDY","78264","CPT","70000255","CDM","341","RC","","Facility","Outpatient","","","1233","986.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","641.16","52","","","Percent of Total Billed Charges","neg_dollar:$641.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","641.16","52","","","Percent of Total Billed Charges","neg_dollar:$641.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","641.16","52","","","Percent of Total Billed Charges","neg_dollar:$641.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","641.16","52","","","Percent of Total Billed Charges","neg_dollar:$641.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1060.37","86","","","Percent of Total Billed Charges","neg_dollar:$1060.37","863.09","70","","","Percent of Total Billed Charges","neg_dollar:$863.09","641.16","52","","","Percent of Total Billed Charges","neg_dollar:$641.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","724.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$724.38;102% of Medicaid interim rate","924.75","75","","","Percent of Total Billed Charges","neg_dollar:$924.75","1060.37","86","","","Percent of Total Billed Charges","neg_dollar:$1060.37","863.09","70","","","Percent of Total Billed Charges","neg_dollar:$863.09","702.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$702.81;103.5% of Medicaid interim rate","1233.00","150","","","Percent of Total Billed Charges","neg_dollar:$1906.27;150% of Medicaid interim rate","986.40","80","","","Percent of Total Billed Charges","neg_dollar:$986.40;Percent of Total Billed Charges","","","","867.00","Fee Schedule","","641.16","52","","","Percent of Total Billed Charges","neg_dollar:$641.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","641.16","52","","","Percent of Total Billed Charges","neg_dollar:$641.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","641.00","1233.00",""
"NM GI BLEED STUDY","78278","CPT","70000256","CDM","341","RC","","Facility","Outpatient","","","1473","1178.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","765.96","52","","","Percent of Total Billed Charges","neg_dollar:$765.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","765.96","52","","","Percent of Total Billed Charges","neg_dollar:$765.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","765.96","52","","","Percent of Total Billed Charges","neg_dollar:$765.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","765.96","52","","","Percent of Total Billed Charges","neg_dollar:$765.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1266.78","86","","","Percent of Total Billed Charges","neg_dollar:$1266.78","1031.10","70","","","Percent of Total Billed Charges","neg_dollar:$1031.10","765.96","52","","","Percent of Total Billed Charges","neg_dollar:$765.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","865.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$865.38;102% of Medicaid interim rate","1104.75","75","","","Percent of Total Billed Charges","neg_dollar:$1104.75","1266.78","86","","","Percent of Total Billed Charges","neg_dollar:$1266.78","1031.10","70","","","Percent of Total Billed Charges","neg_dollar:$1031.10","839.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$839.60;103.5% of Medicaid interim rate","1473.00","150","","","Percent of Total Billed Charges","neg_dollar:$2277.33;150% of Medicaid interim rate","1178.40","80","","","Percent of Total Billed Charges","neg_dollar:$1178.40;Percent of Total Billed Charges","","","","1473.00","Fee Schedule","","765.96","52","","","Percent of Total Billed Charges","neg_dollar:$765.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","765.96","52","","","Percent of Total Billed Charges","neg_dollar:$765.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1473.00",""
"NM MECKELS DIVERT EXAM","78290","CPT","70000257","CDM","341","RC","","Facility","Outpatient","","","1406","1124.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","731.12","52","","","Percent of Total Billed Charges","neg_dollar:$731.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","731.12","52","","","Percent of Total Billed Charges","neg_dollar:$731.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","731.12","52","","","Percent of Total Billed Charges","neg_dollar:$731.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","731.12","52","","","Percent of Total Billed Charges","neg_dollar:$731.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","1209.16","86","","","Percent of Total Billed Charges","neg_dollar:$1209.16","984.19","70","","","Percent of Total Billed Charges","neg_dollar:$984.19","731.12","52","","","Percent of Total Billed Charges","neg_dollar:$731.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","826.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$826.02;102% of Medicaid interim rate","1054.50","75","","","Percent of Total Billed Charges","neg_dollar:$1054.50","1209.16","86","","","Percent of Total Billed Charges","neg_dollar:$1209.16","984.19","70","","","Percent of Total Billed Charges","neg_dollar:$984.19","801.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$801.42;103.5% of Medicaid interim rate","1406.00","150","","","Percent of Total Billed Charges","neg_dollar:$2173.74;150% of Medicaid interim rate","1124.80","80","","","Percent of Total Billed Charges","neg_dollar:$1124.80;Percent of Total Billed Charges","","","","1406.00","Fee Schedule","","731.12","52","","","Percent of Total Billed Charges","neg_dollar:$731.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","731.12","52","","","Percent of Total Billed Charges","neg_dollar:$731.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","731.00","1406.00",""
"NM BONE IMAGING LTD","78300","CPT","70000258","CDM","341","RC","","Facility","Outpatient","","","1089","871.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","566.28","52","","","Percent of Total Billed Charges","neg_dollar:$566.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","566.28","52","","","Percent of Total Billed Charges","neg_dollar:$566.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","566.28","52","","","Percent of Total Billed Charges","neg_dollar:$566.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","566.28","52","","","Percent of Total Billed Charges","neg_dollar:$566.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","936.54","86","","","Percent of Total Billed Charges","neg_dollar:$936.54","762.30","70","","","Percent of Total Billed Charges","neg_dollar:$762.30","566.28","52","","","Percent of Total Billed Charges","neg_dollar:$566.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","639.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$639.78;102% of Medicaid interim rate","816.75","75","","","Percent of Total Billed Charges","neg_dollar:$816.75","936.54","86","","","Percent of Total Billed Charges","neg_dollar:$936.54","762.30","70","","","Percent of Total Billed Charges","neg_dollar:$762.30","620.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$620.72;103.5% of Medicaid interim rate","1089.00","150","","","Percent of Total Billed Charges","neg_dollar:$1683.64;150% of Medicaid interim rate","871.20","80","","","Percent of Total Billed Charges","neg_dollar:$871.20;Percent of Total Billed Charges","","","","1089.00","Fee Schedule","","566.28","52","","","Percent of Total Billed Charges","neg_dollar:$566.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","566.28","52","","","Percent of Total Billed Charges","neg_dollar:$566.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","566.00","1089.00",""
"NM BONE IMAGING MULT AREAS","78305","CPT","70000259","CDM","341","RC","","Facility","Outpatient","","","1922","1537.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","999.44","52","","","Percent of Total Billed Charges","neg_dollar:$999.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","999.44","52","","","Percent of Total Billed Charges","neg_dollar:$999.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","999.44","52","","","Percent of Total Billed Charges","neg_dollar:$999.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","999.44","52","","","Percent of Total Billed Charges","neg_dollar:$999.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","1652.92","86","","","Percent of Total Billed Charges","neg_dollar:$1652.92","1345.39","70","","","Percent of Total Billed Charges","neg_dollar:$1345.39","999.44","52","","","Percent of Total Billed Charges","neg_dollar:$999.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","1129.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1129.17;102% of Medicaid interim rate","1441.50","75","","","Percent of Total Billed Charges","neg_dollar:$1441.50","1652.92","86","","","Percent of Total Billed Charges","neg_dollar:$1652.92","1345.39","70","","","Percent of Total Billed Charges","neg_dollar:$1345.39","1095.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$1095.54;103.5% of Medicaid interim rate","1922.00","150","","","Percent of Total Billed Charges","neg_dollar:$2971.50;150% of Medicaid interim rate","1537.60","80","","","Percent of Total Billed Charges","neg_dollar:$1537.60;Percent of Total Billed Charges","","","","1922.00","Fee Schedule","","999.44","52","","","Percent of Total Billed Charges","neg_dollar:$999.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","999.44","52","","","Percent of Total Billed Charges","neg_dollar:$999.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1922.00",""
"NM BONE IMAGING WHOLE BODY","78306","CPT","70000260","CDM","341","RC","","Facility","Outpatient","","","1535","1228.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","798.20","52","","","Percent of Total Billed Charges","neg_dollar:$798.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","798.20","52","","","Percent of Total Billed Charges","neg_dollar:$798.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","798.20","52","","","Percent of Total Billed Charges","neg_dollar:$798.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","798.20","52","","","Percent of Total Billed Charges","neg_dollar:$798.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","1320.10","86","","","Percent of Total Billed Charges","neg_dollar:$1320.10","1074.50","70","","","Percent of Total Billed Charges","neg_dollar:$1074.50","798.20","52","","","Percent of Total Billed Charges","neg_dollar:$798.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","901.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$901.81;102% of Medicaid interim rate","1151.25","75","","","Percent of Total Billed Charges","neg_dollar:$1151.25","1320.10","86","","","Percent of Total Billed Charges","neg_dollar:$1320.10","1074.50","70","","","Percent of Total Billed Charges","neg_dollar:$1074.50","874.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$874.94;103.5% of Medicaid interim rate","1535.00","150","","","Percent of Total Billed Charges","neg_dollar:$2373.18;150% of Medicaid interim rate","1228.00","80","","","Percent of Total Billed Charges","neg_dollar:$1228;Percent of Total Billed Charges","","","","1535.00","Fee Schedule","","798.20","52","","","Percent of Total Billed Charges","neg_dollar:$798.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","798.20","52","","","Percent of Total Billed Charges","neg_dollar:$798.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1535.00",""
"NM BONE IMAGING 3 PHASE","78315","CPT","70000261","CDM","341","RC","","Facility","Outpatient","","","1720","1376.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","894.40","52","","","Percent of Total Billed Charges","neg_dollar:$894.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","894.40","52","","","Percent of Total Billed Charges","neg_dollar:$894.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","894.40","52","","","Percent of Total Billed Charges","neg_dollar:$894.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","894.40","52","","","Percent of Total Billed Charges","neg_dollar:$894.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1479.20","86","","","Percent of Total Billed Charges","neg_dollar:$1479.20","1204.00","70","","","Percent of Total Billed Charges","neg_dollar:$1204","894.40","52","","","Percent of Total Billed Charges","neg_dollar:$894.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","1010.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$1010.49;102% of Medicaid interim rate","1290.00","75","","","Percent of Total Billed Charges","neg_dollar:$1290","1479.20","86","","","Percent of Total Billed Charges","neg_dollar:$1479.20","1204.00","70","","","Percent of Total Billed Charges","neg_dollar:$1204","980.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$980.39;103.5% of Medicaid interim rate","1720.00","150","","","Percent of Total Billed Charges","neg_dollar:$2659.20;150% of Medicaid interim rate","1376.00","80","","","Percent of Total Billed Charges","neg_dollar:$1376;Percent of Total Billed Charges","","","","1720.00","Fee Schedule","","894.40","52","","","Percent of Total Billed Charges","neg_dollar:$894.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","894.40","52","","","Percent of Total Billed Charges","neg_dollar:$894.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1720.00",""
"NM HEART MUSCLE SPECT SGL","78451","CPT","70000263","CDM","341","RC","","Facility","Outpatient","","","2090","1672.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1086.80","52","","","Percent of Total Billed Charges","neg_dollar:$1086.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1086.80","52","","","Percent of Total Billed Charges","neg_dollar:$1086.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1086.80","52","","","Percent of Total Billed Charges","neg_dollar:$1086.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1086.80","52","","","Percent of Total Billed Charges","neg_dollar:$1086.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1797.39","86","","","Percent of Total Billed Charges","neg_dollar:$1797.39","1463.00","70","","","Percent of Total Billed Charges","neg_dollar:$1463","1086.80","52","","","Percent of Total Billed Charges","neg_dollar:$1086.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","1227.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$1227.87;102% of Medicaid interim rate","1567.50","75","","","Percent of Total Billed Charges","neg_dollar:$1567.50","1797.39","86","","","Percent of Total Billed Charges","neg_dollar:$1797.39","1463.00","70","","","Percent of Total Billed Charges","neg_dollar:$1463","1191.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$1191.30;103.5% of Medicaid interim rate","2090.00","150","","","Percent of Total Billed Charges","neg_dollar:$3231.24;150% of Medicaid interim rate","1672.00","80","","","Percent of Total Billed Charges","neg_dollar:$1672;Percent of Total Billed Charges","","","","2090.00","Fee Schedule","","1086.80","52","","","Percent of Total Billed Charges","neg_dollar:$1086.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1086.80","52","","","Percent of Total Billed Charges","neg_dollar:$1086.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2090.00",""
"NM HEART MUSCLE SPECT MULT","78452","CPT","70000264","CDM","341","RC","","Facility","Outpatient","","","4387","3509.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2281.24","52","","","Percent of Total Billed Charges","neg_dollar:$2281.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2281.24","52","","","Percent of Total Billed Charges","neg_dollar:$2281.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2281.24","52","","","Percent of Total Billed Charges","neg_dollar:$2281.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","2281.24","52","","","Percent of Total Billed Charges","neg_dollar:$2281.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","3772.82","86","","","Percent of Total Billed Charges","neg_dollar:$3772.82","3070.89","70","","","Percent of Total Billed Charges","neg_dollar:$3070.89","2281.24","52","","","Percent of Total Billed Charges","neg_dollar:$2281.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","2577.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$2577.35;102% of Medicaid interim rate","3290.25","75","","","Percent of Total Billed Charges","neg_dollar:$3290.25","3772.82","86","","","Percent of Total Billed Charges","neg_dollar:$3772.82","3070.89","70","","","Percent of Total Billed Charges","neg_dollar:$3070.89","2500.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$2500.58;103.5% of Medicaid interim rate","4387.00","150","","","Percent of Total Billed Charges","neg_dollar:$6782.52;150% of Medicaid interim rate","3509.60","80","","","Percent of Total Billed Charges","neg_dollar:$3509.60;Percent of Total Billed Charges","","","","3486.00","Fee Schedule","","2281.24","52","","","Percent of Total Billed Charges","neg_dollar:$2281.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","2281.24","52","","","Percent of Total Billed Charges","neg_dollar:$2281.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4387.00",""
"NM CARDIAC BLOOD POOL SGL","78472","CPT","70000265","CDM","341","RC","","Facility","Outpatient","","","1570","1256.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","816.40","52","","","Percent of Total Billed Charges","neg_dollar:$816.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","816.40","52","","","Percent of Total Billed Charges","neg_dollar:$816.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","816.40","52","","","Percent of Total Billed Charges","neg_dollar:$816.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","816.40","52","","","Percent of Total Billed Charges","neg_dollar:$816.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1350.20","86","","","Percent of Total Billed Charges","neg_dollar:$1350.20","1099.00","70","","","Percent of Total Billed Charges","neg_dollar:$1099","816.40","52","","","Percent of Total Billed Charges","neg_dollar:$816.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","922.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$922.37;102% of Medicaid interim rate","1177.50","75","","","Percent of Total Billed Charges","neg_dollar:$1177.50","1350.20","86","","","Percent of Total Billed Charges","neg_dollar:$1350.20","1099.00","70","","","Percent of Total Billed Charges","neg_dollar:$1099","894.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$894.90;103.5% of Medicaid interim rate","1570.00","150","","","Percent of Total Billed Charges","neg_dollar:$2427.29;150% of Medicaid interim rate","1256.00","80","","","Percent of Total Billed Charges","neg_dollar:$1256;Percent of Total Billed Charges","","","","1570.00","Fee Schedule","","816.40","52","","","Percent of Total Billed Charges","neg_dollar:$816.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","816.40","52","","","Percent of Total Billed Charges","neg_dollar:$816.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1570.00",""
"NM LUNG VENTILATION IMAGING","78579","CPT","70000592","CDM","341","RC","","Facility","Outpatient","","","969","775.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","503.88","52","","","Percent of Total Billed Charges","neg_dollar:$503.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","503.88","52","","","Percent of Total Billed Charges","neg_dollar:$503.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","503.88","52","","","Percent of Total Billed Charges","neg_dollar:$503.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","503.88","52","","","Percent of Total Billed Charges","neg_dollar:$503.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","833.34","86","","","Percent of Total Billed Charges","neg_dollar:$833.34","678.30","70","","","Percent of Total Billed Charges","neg_dollar:$678.30","503.88","52","","","Percent of Total Billed Charges","neg_dollar:$503.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","569.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$569.28;102% of Medicaid interim rate","726.75","75","","","Percent of Total Billed Charges","neg_dollar:$726.75","833.34","86","","","Percent of Total Billed Charges","neg_dollar:$833.34","678.30","70","","","Percent of Total Billed Charges","neg_dollar:$678.30","552.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$552.32;103.5% of Medicaid interim rate","969.00","150","","","Percent of Total Billed Charges","neg_dollar:$1498.12;150% of Medicaid interim rate","775.20","80","","","Percent of Total Billed Charges","neg_dollar:$775.20;Percent of Total Billed Charges","","","","969.00","Fee Schedule","","503.88","52","","","Percent of Total Billed Charges","neg_dollar:$503.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","503.88","52","","","Percent of Total Billed Charges","neg_dollar:$503.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","503.00","969.00",""
"NM LUNG PERFUSION IMAGING","78580","CPT","70000266","CDM","341","RC","","Facility","Outpatient","","","1014","811.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","527.28","52","","","Percent of Total Billed Charges","neg_dollar:$527.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","527.28","52","","","Percent of Total Billed Charges","neg_dollar:$527.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","527.28","52","","","Percent of Total Billed Charges","neg_dollar:$527.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","527.28","52","","","Percent of Total Billed Charges","neg_dollar:$527.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","872.04","86","","","Percent of Total Billed Charges","neg_dollar:$872.04","709.80","70","","","Percent of Total Billed Charges","neg_dollar:$709.80","527.28","52","","","Percent of Total Billed Charges","neg_dollar:$527.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","595.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$595.72;102% of Medicaid interim rate","760.50","75","","","Percent of Total Billed Charges","neg_dollar:$760.50","872.04","86","","","Percent of Total Billed Charges","neg_dollar:$872.04","709.80","70","","","Percent of Total Billed Charges","neg_dollar:$709.80","577.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$577.97;103.5% of Medicaid interim rate","1014.00","150","","","Percent of Total Billed Charges","neg_dollar:$1567.69;150% of Medicaid interim rate","811.20","80","","","Percent of Total Billed Charges","neg_dollar:$811.20;Percent of Total Billed Charges","","","","1014.00","Fee Schedule","","527.28","52","","","Percent of Total Billed Charges","neg_dollar:$527.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","527.28","52","","","Percent of Total Billed Charges","neg_dollar:$527.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","527.00","1014.00",""
"NM LUNG VENTILAT&PERFUS IMAGING","78582","CPT","70000593","CDM","341","RC","","Facility","Outpatient","","","963","770.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","500.76","52","","","Percent of Total Billed Charges","neg_dollar:$500.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","500.76","52","","","Percent of Total Billed Charges","neg_dollar:$500.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","500.76","52","","","Percent of Total Billed Charges","neg_dollar:$500.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","500.76","52","","","Percent of Total Billed Charges","neg_dollar:$500.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","828.18","86","","","Percent of Total Billed Charges","neg_dollar:$828.18","674.09","70","","","Percent of Total Billed Charges","neg_dollar:$674.09","500.76","52","","","Percent of Total Billed Charges","neg_dollar:$500.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","565.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$565.76;102% of Medicaid interim rate","722.25","75","","","Percent of Total Billed Charges","neg_dollar:$722.25","828.18","86","","","Percent of Total Billed Charges","neg_dollar:$828.18","674.09","70","","","Percent of Total Billed Charges","neg_dollar:$674.09","548.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$548.91;103.5% of Medicaid interim rate","963.00","150","","","Percent of Total Billed Charges","neg_dollar:$1488.84;150% of Medicaid interim rate","770.40","80","","","Percent of Total Billed Charges","neg_dollar:$770.40;Percent of Total Billed Charges","","","","963.00","Fee Schedule","","500.76","52","","","Percent of Total Billed Charges","neg_dollar:$500.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","500.76","52","","","Percent of Total Billed Charges","neg_dollar:$500.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","500.00","963.00",""
"NM KIDNEY FLOW FUNCT WO DRUG","78707","CPT","70000271","CDM","341","RC","","Facility","Outpatient","","","1151","920.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","598.52","52","","","Percent of Total Billed Charges","neg_dollar:$598.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","598.52","52","","","Percent of Total Billed Charges","neg_dollar:$598.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","598.52","52","","","Percent of Total Billed Charges","neg_dollar:$598.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","598.52","52","","","Percent of Total Billed Charges","neg_dollar:$598.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","989.86","86","","","Percent of Total Billed Charges","neg_dollar:$989.86","805.69","70","","","Percent of Total Billed Charges","neg_dollar:$805.69","598.52","52","","","Percent of Total Billed Charges","neg_dollar:$598.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","676.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$676.21;102% of Medicaid interim rate","863.25","75","","","Percent of Total Billed Charges","neg_dollar:$863.25","989.86","86","","","Percent of Total Billed Charges","neg_dollar:$989.86","805.69","70","","","Percent of Total Billed Charges","neg_dollar:$805.69","656.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$656.06;103.5% of Medicaid interim rate","1151.00","150","","","Percent of Total Billed Charges","neg_dollar:$1779.50;150% of Medicaid interim rate","920.80","80","","","Percent of Total Billed Charges","neg_dollar:$920.80;Percent of Total Billed Charges","","","","1151.00","Fee Schedule","","598.52","52","","","Percent of Total Billed Charges","neg_dollar:$598.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","598.52","52","","","Percent of Total Billed Charges","neg_dollar:$598.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","598.00","1151.00",""
"NM KIDNEY FLOW FUNCT W DRUG","78708","CPT","70000272","CDM","341","RC","","Facility","Outpatient","","","1263","1010.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","656.76","52","","","Percent of Total Billed Charges","neg_dollar:$656.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","656.76","52","","","Percent of Total Billed Charges","neg_dollar:$656.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","656.76","52","","","Percent of Total Billed Charges","neg_dollar:$656.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","656.76","52","","","Percent of Total Billed Charges","neg_dollar:$656.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1086.18","86","","","Percent of Total Billed Charges","neg_dollar:$1086.18","884.09","70","","","Percent of Total Billed Charges","neg_dollar:$884.09","656.76","52","","","Percent of Total Billed Charges","neg_dollar:$656.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","742.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$742.01;102% of Medicaid interim rate","947.25","75","","","Percent of Total Billed Charges","neg_dollar:$947.25","1086.18","86","","","Percent of Total Billed Charges","neg_dollar:$1086.18","884.09","70","","","Percent of Total Billed Charges","neg_dollar:$884.09","719.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$719.91;103.5% of Medicaid interim rate","1263.00","150","","","Percent of Total Billed Charges","neg_dollar:$1952.66;150% of Medicaid interim rate","1010.40","80","","","Percent of Total Billed Charges","neg_dollar:$1010.40;Percent of Total Billed Charges","","","","1053.00","Fee Schedule","","656.76","52","","","Percent of Total Billed Charges","neg_dollar:$656.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","656.76","52","","","Percent of Total Billed Charges","neg_dollar:$656.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","656.00","1263.00",""
"NM TESTICULAR IMAGING W/FLOW","78761","CPT","70000685","CDM","341","RC","","Facility","Outpatient","","","1022","817.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","531.44","52","","","Percent of Total Billed Charges","neg_dollar:$531.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","531.44","52","","","Percent of Total Billed Charges","neg_dollar:$531.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","531.44","52","","","Percent of Total Billed Charges","neg_dollar:$531.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","531.44","52","","","Percent of Total Billed Charges","neg_dollar:$531.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","878.92","86","","","Percent of Total Billed Charges","neg_dollar:$878.92","715.40","70","","","Percent of Total Billed Charges","neg_dollar:$715.40","531.44","52","","","Percent of Total Billed Charges","neg_dollar:$531.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","600.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$600.42;102% of Medicaid interim rate","766.50","75","","","Percent of Total Billed Charges","neg_dollar:$766.50","878.92","86","","","Percent of Total Billed Charges","neg_dollar:$878.92","715.40","70","","","Percent of Total Billed Charges","neg_dollar:$715.40","582.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$582.54;103.5% of Medicaid interim rate","1022.00","150","","","Percent of Total Billed Charges","neg_dollar:$1580.06;150% of Medicaid interim rate","817.60","80","","","Percent of Total Billed Charges","neg_dollar:$817.60;Percent of Total Billed Charges","","","","1022.00","Fee Schedule","","531.44","52","","","Percent of Total Billed Charges","neg_dollar:$531.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","531.44","52","","","Percent of Total Billed Charges","neg_dollar:$531.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","531.00","1022.00",""
"AUTOM URINE DIP W MICRO","81001","CPT","80000073","CDM","307","RC","","Facility","Outpatient","","","59","47.20","59.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","59.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.74","86","","","Percent of Total Billed Charges","neg_dollar:$50.74","41.30","70","","","Percent of Total Billed Charges","neg_dollar:$41.30","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","34.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.66;102% of Medicaid interim rate","44.25","75","","","Percent of Total Billed Charges","neg_dollar:$44.25","50.74","86","","","Percent of Total Billed Charges","neg_dollar:$50.74","41.30","70","","","Percent of Total Billed Charges","neg_dollar:$41.30","33.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.62;103.5% of Medicaid interim rate","59.00","150","","","Percent of Total Billed Charges","neg_dollar:$91.21;150% of Medicaid interim rate","47.20","80","","","Percent of Total Billed Charges","neg_dollar:$47.20;Percent of Total Billed Charges","","","","44.00","Fee Schedule","","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","30.00","59.00",""
"N-AUTOM URINALYS WO MICRO","81002","CPT","80000015","CDM","307","RC","","Facility","Outpatient","","","30","24.00","30.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","30.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","25.80","86","","","Percent of Total Billed Charges","neg_dollar:$25.80","21.00","70","","","Percent of Total Billed Charges","neg_dollar:$21","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","17.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.62;102% of Medicaid interim rate","22.50","75","","","Percent of Total Billed Charges","neg_dollar:$22.50","25.80","86","","","Percent of Total Billed Charges","neg_dollar:$25.80","21.00","70","","","Percent of Total Billed Charges","neg_dollar:$21","17.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.09;103.5% of Medicaid interim rate","30.00","150","","","Percent of Total Billed Charges","neg_dollar:$46.38;150% of Medicaid interim rate","24.00","80","","","Percent of Total Billed Charges","neg_dollar:$24;Percent of Total Billed Charges","","","","30.00","Fee Schedule","","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.00","30.00",""
"AUTOM URINALYSIS WO MICRO","81003","CPT","80000016","CDM","307","RC","","Facility","Outpatient","","","30","24.00","30.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","30.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","25.80","86","","","Percent of Total Billed Charges","neg_dollar:$25.80","21.00","70","","","Percent of Total Billed Charges","neg_dollar:$21","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","17.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.62;102% of Medicaid interim rate","22.50","75","","","Percent of Total Billed Charges","neg_dollar:$22.50","25.80","86","","","Percent of Total Billed Charges","neg_dollar:$25.80","21.00","70","","","Percent of Total Billed Charges","neg_dollar:$21","17.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.09;103.5% of Medicaid interim rate","30.00","150","","","Percent of Total Billed Charges","neg_dollar:$46.38;150% of Medicaid interim rate","24.00","80","","","Percent of Total Billed Charges","neg_dollar:$24;Percent of Total Billed Charges","","","","23.00","Fee Schedule","","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.60","52","","","Percent of Total Billed Charges","neg_dollar:$15.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.00","30.00",""
"URINE PREGNANCY, VISUAL COLOR","81025","CPT","80000017","CDM","307","RC","","Facility","Outpatient","","","65","52.00","65.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","65.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","55.90","86","","","Percent of Total Billed Charges","neg_dollar:$55.90","45.50","70","","","Percent of Total Billed Charges","neg_dollar:$45.50","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","38.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$38.18;102% of Medicaid interim rate","48.75","75","","","Percent of Total Billed Charges","neg_dollar:$48.75","55.90","86","","","Percent of Total Billed Charges","neg_dollar:$55.90","45.50","70","","","Percent of Total Billed Charges","neg_dollar:$45.50","37.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.05;103.5% of Medicaid interim rate","65.00","150","","","Percent of Total Billed Charges","neg_dollar:$100.49;150% of Medicaid interim rate","52.00","80","","","Percent of Total Billed Charges","neg_dollar:$52;Percent of Total Billed Charges","","","","52.00","Fee Schedule","","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","65.00",""
"OCCULT BLOOD FECES","82270","CPT","80000010","CDM","301","RC","","Facility","Outpatient","","","65","52.00","65.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","65.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","55.90","86","","","Percent of Total Billed Charges","neg_dollar:$55.90","45.50","70","","","Percent of Total Billed Charges","neg_dollar:$45.50","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","38.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$38.18;102% of Medicaid interim rate","48.75","75","","","Percent of Total Billed Charges","neg_dollar:$48.75","55.90","86","","","Percent of Total Billed Charges","neg_dollar:$55.90","45.50","70","","","Percent of Total Billed Charges","neg_dollar:$45.50","37.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.05;103.5% of Medicaid interim rate","65.00","150","","","Percent of Total Billed Charges","neg_dollar:$100.49;150% of Medicaid interim rate","52.00","80","","","Percent of Total Billed Charges","neg_dollar:$52;Percent of Total Billed Charges","","","","43.00","Fee Schedule","","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","65.00",""
"OCCULT BLD FECES, 1-3 TESTS","82272","CPT","80000115","CDM","301","RC","","Facility","Outpatient","","","65","52.00","65.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","65.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","55.90","86","","","Percent of Total Billed Charges","neg_dollar:$55.90","45.50","70","","","Percent of Total Billed Charges","neg_dollar:$45.50","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","38.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$38.18;102% of Medicaid interim rate","48.75","75","","","Percent of Total Billed Charges","neg_dollar:$48.75","55.90","86","","","Percent of Total Billed Charges","neg_dollar:$55.90","45.50","70","","","Percent of Total Billed Charges","neg_dollar:$45.50","37.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.05;103.5% of Medicaid interim rate","65.00","150","","","Percent of Total Billed Charges","neg_dollar:$100.49;150% of Medicaid interim rate","52.00","80","","","Percent of Total Billed Charges","neg_dollar:$52;Percent of Total Billed Charges","","","","24.00","Fee Schedule","","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.80","52","","","Percent of Total Billed Charges","neg_dollar:$33.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","24.00","65.00",""
"OCCULT BLD IA SCRN CRC","82274","CPT","80001135","CDM","305","RC","","Facility","Outpatient","","","70","56.00","70.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","36.40","52","","","Percent of Total Billed Charges","neg_dollar:$36.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","70.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","36.40","52","","","Percent of Total Billed Charges","neg_dollar:$36.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","36.40","52","","","Percent of Total Billed Charges","neg_dollar:$36.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","36.40","52","","","Percent of Total Billed Charges","neg_dollar:$36.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","60.19","86","","","Percent of Total Billed Charges","neg_dollar:$60.19","49.00","70","","","Percent of Total Billed Charges","neg_dollar:$49","36.40","52","","","Percent of Total Billed Charges","neg_dollar:$36.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","41.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$41.12;102% of Medicaid interim rate","52.50","75","","","Percent of Total Billed Charges","neg_dollar:$52.50","60.19","86","","","Percent of Total Billed Charges","neg_dollar:$60.19","49.00","70","","","Percent of Total Billed Charges","neg_dollar:$49","39.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$39.90;103.5% of Medicaid interim rate","70.00","150","","","Percent of Total Billed Charges","neg_dollar:$108.22;150% of Medicaid interim rate","56.00","80","","","Percent of Total Billed Charges","neg_dollar:$56;Percent of Total Billed Charges","","","","70.00","Fee Schedule","","36.40","52","","","Percent of Total Billed Charges","neg_dollar:$36.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","36.40","52","","","Percent of Total Billed Charges","neg_dollar:$36.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","36.00","70.00",""
"GLUCOSE; BLOOD REAGENT STRIP","82948","CPT","80001116","CDM","301","RC","","Facility","Outpatient","","","20","16.00","20.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","10.40","52","","","Percent of Total Billed Charges","neg_dollar:$10.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","20.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","10.40","52","","","Percent of Total Billed Charges","neg_dollar:$10.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.40","52","","","Percent of Total Billed Charges","neg_dollar:$10.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.40","52","","","Percent of Total Billed Charges","neg_dollar:$10.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.20","86","","","Percent of Total Billed Charges","neg_dollar:$17.20","14.00","70","","","Percent of Total Billed Charges","neg_dollar:$14","10.40","52","","","Percent of Total Billed Charges","neg_dollar:$10.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","11.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.74;102% of Medicaid interim rate","15.00","75","","","Percent of Total Billed Charges","neg_dollar:$15","17.20","86","","","Percent of Total Billed Charges","neg_dollar:$17.20","14.00","70","","","Percent of Total Billed Charges","neg_dollar:$14","11.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.39;103.5% of Medicaid interim rate","20.00","150","","","Percent of Total Billed Charges","neg_dollar:$30.92;150% of Medicaid interim rate","16.00","80","","","Percent of Total Billed Charges","neg_dollar:$16;Percent of Total Billed Charges","","","","20.00","Fee Schedule","","10.40","52","","","Percent of Total Billed Charges","neg_dollar:$10.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.40","52","","","Percent of Total Billed Charges","neg_dollar:$10.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.00","20.00",""
"GLUCOSE BLD BY MONITOR DEVICE","82962","CPT","80000012","CDM","301","RC","","Facility","Outpatient","","","63","50.40","63.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","63.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","54.18","86","","","Percent of Total Billed Charges","neg_dollar:$54.18","44.09","70","","","Percent of Total Billed Charges","neg_dollar:$44.09","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","37.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.01;102% of Medicaid interim rate","47.25","75","","","Percent of Total Billed Charges","neg_dollar:$47.25","54.18","86","","","Percent of Total Billed Charges","neg_dollar:$54.18","44.09","70","","","Percent of Total Billed Charges","neg_dollar:$44.09","35.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.91;103.5% of Medicaid interim rate","63.00","150","","","Percent of Total Billed Charges","neg_dollar:$97.40;150% of Medicaid interim rate","50.40","80","","","Percent of Total Billed Charges","neg_dollar:$50.40;Percent of Total Billed Charges","","","","31.00","Fee Schedule","","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","31.00","63.00",""
"HEMOGLOBIN GLYCOSYLATED TEST (A1C)","83036","CPT","80000019","CDM","301","RC","","Facility","Outpatient","","","117","93.60","117.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","60.84","52","","","Percent of Total Billed Charges","neg_dollar:$60.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","117.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","60.84","52","","","Percent of Total Billed Charges","neg_dollar:$60.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","60.84","52","","","Percent of Total Billed Charges","neg_dollar:$60.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","60.84","52","","","Percent of Total Billed Charges","neg_dollar:$60.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","100.62","86","","","Percent of Total Billed Charges","neg_dollar:$100.62","81.89","70","","","Percent of Total Billed Charges","neg_dollar:$81.89","60.84","52","","","Percent of Total Billed Charges","neg_dollar:$60.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","68.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.73;102% of Medicaid interim rate","87.75","75","","","Percent of Total Billed Charges","neg_dollar:$87.75","100.62","86","","","Percent of Total Billed Charges","neg_dollar:$100.62","81.89","70","","","Percent of Total Billed Charges","neg_dollar:$81.89","66.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.69;103.5% of Medicaid interim rate","117.00","150","","","Percent of Total Billed Charges","neg_dollar:$180.88;150% of Medicaid interim rate","93.60","80","","","Percent of Total Billed Charges","neg_dollar:$93.60;Percent of Total Billed Charges","","","","92.00","Fee Schedule","","60.84","52","","","Percent of Total Billed Charges","neg_dollar:$60.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","60.84","52","","","Percent of Total Billed Charges","neg_dollar:$60.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","60.00","117.00",""
"HEMOGLOBIN","85018","CPT","80000352","CDM","305","RC","","Facility","Outpatient","","","58","46.40","58.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","30.16","52","","","Percent of Total Billed Charges","neg_dollar:$30.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","58.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","30.16","52","","","Percent of Total Billed Charges","neg_dollar:$30.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.16","52","","","Percent of Total Billed Charges","neg_dollar:$30.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.16","52","","","Percent of Total Billed Charges","neg_dollar:$30.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","49.88","86","","","Percent of Total Billed Charges","neg_dollar:$49.88","40.59","70","","","Percent of Total Billed Charges","neg_dollar:$40.59","30.16","52","","","Percent of Total Billed Charges","neg_dollar:$30.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","34.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.07;102% of Medicaid interim rate","43.50","75","","","Percent of Total Billed Charges","neg_dollar:$43.50","49.88","86","","","Percent of Total Billed Charges","neg_dollar:$49.88","40.59","70","","","Percent of Total Billed Charges","neg_dollar:$40.59","33.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.05;103.5% of Medicaid interim rate","58.00","150","","","Percent of Total Billed Charges","neg_dollar:$89.67;150% of Medicaid interim rate","46.40","80","","","Percent of Total Billed Charges","neg_dollar:$46.40;Percent of Total Billed Charges","","","","45.00","Fee Schedule","","30.16","52","","","Percent of Total Billed Charges","neg_dollar:$30.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","30.16","52","","","Percent of Total Billed Charges","neg_dollar:$30.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","30.00","58.00",""
"PROTHROMBIN TIME","85610","CPT","80000394","CDM","305","RC","","Facility","Outpatient","","","59","47.20","59.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","59.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.74","86","","","Percent of Total Billed Charges","neg_dollar:$50.74","41.30","70","","","Percent of Total Billed Charges","neg_dollar:$41.30","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","34.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.66;102% of Medicaid interim rate","44.25","75","","","Percent of Total Billed Charges","neg_dollar:$44.25","50.74","86","","","Percent of Total Billed Charges","neg_dollar:$50.74","41.30","70","","","Percent of Total Billed Charges","neg_dollar:$41.30","33.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.62;103.5% of Medicaid interim rate","59.00","150","","","Percent of Total Billed Charges","neg_dollar:$91.21;150% of Medicaid interim rate","47.20","80","","","Percent of Total Billed Charges","neg_dollar:$47.20;Percent of Total Billed Charges","","","","41.00","Fee Schedule","","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","30.68","52","","","Percent of Total Billed Charges","neg_dollar:$30.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","30.00","59.00",""
"SKIN TEST; TB, ID","86580","CPT","80000461","CDM","302","RC","","Facility","Outpatient","","","64","51.20","64.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","33.28","52","","","Percent of Total Billed Charges","neg_dollar:$33.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","64.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","33.28","52","","","Percent of Total Billed Charges","neg_dollar:$33.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.28","52","","","Percent of Total Billed Charges","neg_dollar:$33.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.28","52","","","Percent of Total Billed Charges","neg_dollar:$33.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","55.04","86","","","Percent of Total Billed Charges","neg_dollar:$55.04","44.80","70","","","Percent of Total Billed Charges","neg_dollar:$44.80","33.28","52","","","Percent of Total Billed Charges","neg_dollar:$33.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","37.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.59;102% of Medicaid interim rate","48.00","75","","","Percent of Total Billed Charges","neg_dollar:$48","55.04","86","","","Percent of Total Billed Charges","neg_dollar:$55.04","44.80","70","","","Percent of Total Billed Charges","neg_dollar:$44.80","36.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$36.48;103.5% of Medicaid interim rate","64.00","150","","","Percent of Total Billed Charges","neg_dollar:$98.94;150% of Medicaid interim rate","51.20","80","","","Percent of Total Billed Charges","neg_dollar:$51.20;Percent of Total Billed Charges","","","","45.00","Fee Schedule","","33.28","52","","","Percent of Total Billed Charges","neg_dollar:$33.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.28","52","","","Percent of Total Billed Charges","neg_dollar:$33.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","64.00",""
"INFLUENZA DNA AMP PROBE 2 TYPES","87502","CPT","80000911","CDM","306","RC","","Facility","Outpatient","","","528","422.40","528.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","274.56","52","","","Percent of Total Billed Charges","neg_dollar:$274.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","528.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","274.56","52","","","Percent of Total Billed Charges","neg_dollar:$274.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","274.56","52","","","Percent of Total Billed Charges","neg_dollar:$274.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","274.56","52","","","Percent of Total Billed Charges","neg_dollar:$274.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","454.08","86","","","Percent of Total Billed Charges","neg_dollar:$454.08","369.59","70","","","Percent of Total Billed Charges","neg_dollar:$369.59","274.56","52","","","Percent of Total Billed Charges","neg_dollar:$274.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","310.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$310.19;102% of Medicaid interim rate","396.00","75","","","Percent of Total Billed Charges","neg_dollar:$396","454.08","86","","","Percent of Total Billed Charges","neg_dollar:$454.08","369.59","70","","","Percent of Total Billed Charges","neg_dollar:$369.59","300.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$300.96;103.5% of Medicaid interim rate","528.00","150","","","Percent of Total Billed Charges","neg_dollar:$816.31;150% of Medicaid interim rate","422.40","80","","","Percent of Total Billed Charges","neg_dollar:$422.40;Percent of Total Billed Charges","","","","263.00","Fee Schedule","","274.56","52","","","Percent of Total Billed Charges","neg_dollar:$274.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","274.56","52","","","Percent of Total Billed Charges","neg_dollar:$274.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","263.00","528.00",""
"RSV DNA/RNA AMP PROBE","87634","CPT","80001852","CDM","306","RC","","Facility","Outpatient","","","390","312.00","390.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","335.40","86","","","Percent of Total Billed Charges","neg_dollar:$335.40","273.00","70","","","Percent of Total Billed Charges","neg_dollar:$273","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","229.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$229.12;102% of Medicaid interim rate","292.50","75","","","Percent of Total Billed Charges","neg_dollar:$292.50","335.40","86","","","Percent of Total Billed Charges","neg_dollar:$335.40","273.00","70","","","Percent of Total Billed Charges","neg_dollar:$273","222.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$222.29;103.5% of Medicaid interim rate","390.00","150","","","Percent of Total Billed Charges","neg_dollar:$602.95;150% of Medicaid interim rate","312.00","80","","","Percent of Total Billed Charges","neg_dollar:$312;Percent of Total Billed Charges","","","","235.00","Fee Schedule","","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","202.00","390.00",""
"COVID-19 LAB TEST NON-CDC AMP PRB","87635","CPT","80001964","CDM","300","RC","","Facility","Outpatient","","","148","118.40","148.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","76.96","52","","","Percent of Total Billed Charges","neg_dollar:$76.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","148.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","76.96","52","","","Percent of Total Billed Charges","neg_dollar:$76.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.96","52","","","Percent of Total Billed Charges","neg_dollar:$76.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.96","52","","","Percent of Total Billed Charges","neg_dollar:$76.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","127.28","86","","","Percent of Total Billed Charges","neg_dollar:$127.28","103.60","70","","","Percent of Total Billed Charges","neg_dollar:$103.60","76.96","52","","","Percent of Total Billed Charges","neg_dollar:$76.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","86.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$86.94;102% of Medicaid interim rate","111.00","75","","","Percent of Total Billed Charges","neg_dollar:$111","127.28","86","","","Percent of Total Billed Charges","neg_dollar:$127.28","103.60","70","","","Percent of Total Billed Charges","neg_dollar:$103.60","84.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$84.36;103.5% of Medicaid interim rate","148.00","150","","","Percent of Total Billed Charges","neg_dollar:$228.81;150% of Medicaid interim rate","118.40","80","","","Percent of Total Billed Charges","neg_dollar:$118.40;Percent of Total Billed Charges","","","","117.00","Fee Schedule","","76.96","52","","","Percent of Total Billed Charges","neg_dollar:$76.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","76.96","52","","","Percent of Total Billed Charges","neg_dollar:$76.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","76.00","148.00",""
"STREP A AMPLIF NA PROBE","87651","CPT","80001230","CDM","300","RC","","Facility","Outpatient","","","240","192.00","240.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","240.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","206.40","86","","","Percent of Total Billed Charges","neg_dollar:$206.40","168.00","70","","","Percent of Total Billed Charges","neg_dollar:$168","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","140.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$140.99;102% of Medicaid interim rate","180.00","75","","","Percent of Total Billed Charges","neg_dollar:$180","206.40","86","","","Percent of Total Billed Charges","neg_dollar:$206.40","168.00","70","","","Percent of Total Billed Charges","neg_dollar:$168","136.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$136.79;103.5% of Medicaid interim rate","240.00","150","","","Percent of Total Billed Charges","neg_dollar:$371.05;150% of Medicaid interim rate","192.00","80","","","Percent of Total Billed Charges","neg_dollar:$192;Percent of Total Billed Charges","","","","190.00","Fee Schedule","","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","124.80","52","","","Percent of Total Billed Charges","neg_dollar:$124.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","124.00","240.00",""
"INFLUENZA IA W DO","87804","CPT","80000826","CDM","306","RC","","Facility","Outpatient","","","113","90.40","113.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","113.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","97.17","86","","","Percent of Total Billed Charges","neg_dollar:$97.17","79.10","70","","","Percent of Total Billed Charges","neg_dollar:$79.10","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","66.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.38;102% of Medicaid interim rate","84.75","75","","","Percent of Total Billed Charges","neg_dollar:$84.75","97.17","86","","","Percent of Total Billed Charges","neg_dollar:$97.17","79.10","70","","","Percent of Total Billed Charges","neg_dollar:$79.10","64.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.41;103.5% of Medicaid interim rate","113.00","150","","","Percent of Total Billed Charges","neg_dollar:$174.70;150% of Medicaid interim rate","90.40","80","","","Percent of Total Billed Charges","neg_dollar:$90.40;Percent of Total Billed Charges","","","","113.00","Fee Schedule","","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.00","113.00",""
"SARS-COV-2 COVID19 W/OPTIC","87811","CPT","80001980","CDM","306","RC","","Facility","Outpatient","","","147","117.60","147.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","147.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","126.42","86","","","Percent of Total Billed Charges","neg_dollar:$126.42","102.89","70","","","Percent of Total Billed Charges","neg_dollar:$102.89","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","86.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$86.36;102% of Medicaid interim rate","110.25","75","","","Percent of Total Billed Charges","neg_dollar:$110.25","126.42","86","","","Percent of Total Billed Charges","neg_dollar:$126.42","102.89","70","","","Percent of Total Billed Charges","neg_dollar:$102.89","83.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$83.78;103.5% of Medicaid interim rate","147.00","150","","","Percent of Total Billed Charges","neg_dollar:$227.26;150% of Medicaid interim rate","117.60","80","","","Percent of Total Billed Charges","neg_dollar:$117.60;Percent of Total Billed Charges","","","","70.00","Fee Schedule","","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","70.00","147.00",""
"STREP A ASSAY W/OPTIC","87880","CPT","80000811","CDM","306","RC","","Facility","Outpatient","","","92","73.60","92.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","92.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","79.12","86","","","Percent of Total Billed Charges","neg_dollar:$79.12","64.39","70","","","Percent of Total Billed Charges","neg_dollar:$64.39","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","54.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.04;102% of Medicaid interim rate","69.00","75","","","Percent of Total Billed Charges","neg_dollar:$69","79.12","86","","","Percent of Total Billed Charges","neg_dollar:$79.12","64.39","70","","","Percent of Total Billed Charges","neg_dollar:$64.39","52.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.44;103.5% of Medicaid interim rate","92.00","150","","","Percent of Total Billed Charges","neg_dollar:$142.23;150% of Medicaid interim rate","73.60","80","","","Percent of Total Billed Charges","neg_dollar:$73.60;Percent of Total Billed Charges","","","","92.00","Fee Schedule","","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.00","92.00",""
"AEROSOL SPUTUM COLLECT","89220","CPT","80000009","CDM","309","RC","","Facility","Outpatient","","","150","120.00","150.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;101% Medicare Outpatient Cost to Charge Ratio of 52%","150.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;102% Medicare Outpatient Cost to Charge Ratio of 52%","129.00","86","","","Percent of Total Billed Charges","neg_dollar:$129","105.00","70","","","Percent of Total Billed Charges","neg_dollar:$105","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;105% Medicare Outpatient Cost to Charge Ratio of 52%","88.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$88.12;102% of Medicaid interim rate","112.50","75","","","Percent of Total Billed Charges","neg_dollar:$112.50","129.00","86","","","Percent of Total Billed Charges","neg_dollar:$129","105.00","70","","","Percent of Total Billed Charges","neg_dollar:$105","85.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$85.49;103.5% of Medicaid interim rate","150.00","150","","","Percent of Total Billed Charges","neg_dollar:$231.90;150% of Medicaid interim rate","120.00","80","","","Percent of Total Billed Charges","neg_dollar:$120;Percent of Total Billed Charges","","","","119.00","Fee Schedule","","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;100% Medicare Outpatient Cost to Charge Ratio of 52%","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;100% Medicare Outpatient Cost to Charge Ratio of 52%","78.00","150.00",""
"RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN","90375","CPT","13533-318-01","NDC","636","RC","","Facility","Outpatient","1","EA","598.85","598.85","","","","598.85","Fee Schedule","","","","","598.85","Fee Schedule","101% of Medicare Fee Schedule","","","","598.85","Fee Schedule","","311.40","52","","","Percent of Total Billed Charges","neg_dollar:$311.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","598.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","598.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","515.01","86","","","Percent of Total Billed Charges","neg_dollar:$515.01","419.19","70","","","Percent of Total Billed Charges","neg_dollar:$419.19","311.40","52","","","Percent of Total Billed Charges","neg_dollar:$311.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","351.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$351.82;102% of Medicaid interim rate","449.13","75","","","Percent of Total Billed Charges","neg_dollar:$449.13","515.01","86","","","Percent of Total Billed Charges","neg_dollar:$515.01","419.19","70","","","Percent of Total Billed Charges","neg_dollar:$419.19","341.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$341.34;103.5% of Medicaid interim rate","598.85","150","","","Percent of Total Billed Charges","neg_dollar:$925.85;150% of Medicaid interim rate","479.08","80","","","Percent of Total Billed Charges","neg_dollar:$479.08;Percent of Total Billed Charges","550.94","92","","","Percent of Total Billed Charges","neg_dollar:$550.94","311.40","52","","","Percent of Total Billed Charges","neg_dollar:$311.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","311.40","52","","","Percent of Total Billed Charges","neg_dollar:$311.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","311.00","598.00",""
"RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN","90375","CPT","13533-318-01","NDC","636","RC","","Facility","Outpatient","1","EA","537.28","537.28","","","","537.28","Fee Schedule","","","","","537.28","Fee Schedule","101% of Medicare Fee Schedule","","","","537.28","Fee Schedule","","279.38","52","","","Percent of Total Billed Charges","neg_dollar:$279.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","537.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","537.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","462.06","86","","","Percent of Total Billed Charges","neg_dollar:$462.06","376.09","70","","","Percent of Total Billed Charges","neg_dollar:$376.09","279.38","52","","","Percent of Total Billed Charges","neg_dollar:$279.38;105% Medicare Outpatient Cost to Charge Ratio of 52%","315.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$315.65;102% of Medicaid interim rate","402.96","75","","","Percent of Total Billed Charges","neg_dollar:$402.96","462.06","86","","","Percent of Total Billed Charges","neg_dollar:$462.06","376.09","70","","","Percent of Total Billed Charges","neg_dollar:$376.09","306.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$306.25;103.5% of Medicaid interim rate","537.28","150","","","Percent of Total Billed Charges","neg_dollar:$830.66;150% of Medicaid interim rate","429.82","80","","","Percent of Total Billed Charges","neg_dollar:$429.82;Percent of Total Billed Charges","494.30","92","","","Percent of Total Billed Charges","neg_dollar:$494.30","279.38","52","","","Percent of Total Billed Charges","neg_dollar:$279.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.38","52","","","Percent of Total Billed Charges","neg_dollar:$279.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.00","537.00",""
"RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN","90375","CPT","13533-318-10","NDC","636","RC","","Facility","Outpatient","1","EA","659.31","659.31","","","","659.31","Fee Schedule","","","","","659.31","Fee Schedule","101% of Medicare Fee Schedule","","","","659.31","Fee Schedule","","342.84","52","","","Percent of Total Billed Charges","neg_dollar:$342.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","659.31","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","659.31","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","567.00","86","","","Percent of Total Billed Charges","neg_dollar:$567","461.51","70","","","Percent of Total Billed Charges","neg_dollar:$461.51","342.84","52","","","Percent of Total Billed Charges","neg_dollar:$342.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","387.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$387.34;102% of Medicaid interim rate","494.48","75","","","Percent of Total Billed Charges","neg_dollar:$494.48","567.00","86","","","Percent of Total Billed Charges","neg_dollar:$567","461.51","70","","","Percent of Total Billed Charges","neg_dollar:$461.51","375.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$375.80;103.5% of Medicaid interim rate","659.31","150","","","Percent of Total Billed Charges","neg_dollar:$1019.32;150% of Medicaid interim rate","527.44","80","","","Percent of Total Billed Charges","neg_dollar:$527.44;Percent of Total Billed Charges","606.56","92","","","Percent of Total Billed Charges","neg_dollar:$606.56","342.84","52","","","Percent of Total Billed Charges","neg_dollar:$342.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","342.84","52","","","Percent of Total Billed Charges","neg_dollar:$342.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","342.00","659.00",""
"IM ADMIN 1ST/ONLY W COUNSEL AGE 0-18","90460","CPT","90000834","CDM","771","RC","","Facility","Outpatient","","","92","73.60","92.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","92.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","79.12","86","","","Percent of Total Billed Charges","neg_dollar:$79.12","64.39","70","","","Percent of Total Billed Charges","neg_dollar:$64.39","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","54.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.04;102% of Medicaid interim rate","69.00","75","","","Percent of Total Billed Charges","neg_dollar:$69","79.12","86","","","Percent of Total Billed Charges","neg_dollar:$79.12","64.39","70","","","Percent of Total Billed Charges","neg_dollar:$64.39","52.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.44;103.5% of Medicaid interim rate","92.00","150","","","Percent of Total Billed Charges","neg_dollar:$142.23;150% of Medicaid interim rate","73.60","80","","","Percent of Total Billed Charges","neg_dollar:$73.60;Percent of Total Billed Charges","84.64","92","","","Percent of Total Billed Charges","neg_dollar:$84.64","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.84","52","","","Percent of Total Billed Charges","neg_dollar:$47.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.00","92.00",""
"IM ADMIN EA ADDTL W COUNSEL AGE 0-18","90461","CPT","90000835","CDM","771","RC","","Facility","Outpatient","","","53","42.40","53.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","53.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.58","86","","","Percent of Total Billed Charges","neg_dollar:$45.58","37.09","70","","","Percent of Total Billed Charges","neg_dollar:$37.09","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","31.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.13;102% of Medicaid interim rate","39.75","75","","","Percent of Total Billed Charges","neg_dollar:$39.75","45.58","86","","","Percent of Total Billed Charges","neg_dollar:$45.58","37.09","70","","","Percent of Total Billed Charges","neg_dollar:$37.09","30.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.20;103.5% of Medicaid interim rate","53.00","150","","","Percent of Total Billed Charges","neg_dollar:$81.94;150% of Medicaid interim rate","42.40","80","","","Percent of Total Billed Charges","neg_dollar:$42.40;Percent of Total Billed Charges","48.76","92","","","Percent of Total Billed Charges","neg_dollar:$48.76","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.00","53.00",""
"IMMUNIZATION ADM 1 VACCINE","90471","CPT","90000001","CDM","771","RC","","Facility","Outpatient","","","120","96.00","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","70.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$70.49;102% of Medicaid interim rate","90.00","75","","","Percent of Total Billed Charges","neg_dollar:$90","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","68.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.39;103.5% of Medicaid interim rate","120.00","150","","","Percent of Total Billed Charges","neg_dollar:$185.52;150% of Medicaid interim rate","96.00","80","","","Percent of Total Billed Charges","neg_dollar:$96;Percent of Total Billed Charges","110.40","92","","","Percent of Total Billed Charges","neg_dollar:$110.40","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","120.00",""
"ADMIN PNEUMONIA VACCINE","90471","CPT","90000281","CDM","771","RC","","Facility","Outpatient","","","120","96.00","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","70.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$70.49;102% of Medicaid interim rate","90.00","75","","","Percent of Total Billed Charges","neg_dollar:$90","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","68.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.39;103.5% of Medicaid interim rate","120.00","150","","","Percent of Total Billed Charges","neg_dollar:$185.52;150% of Medicaid interim rate","96.00","80","","","Percent of Total Billed Charges","neg_dollar:$96;Percent of Total Billed Charges","110.40","92","","","Percent of Total Billed Charges","neg_dollar:$110.40","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","120.00",""
"ADMIN INFLUENZA VIRUS VACCINE","90471","CPT","90000282","CDM","771","RC","","Facility","Outpatient","","","120","96.00","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","70.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$70.49;102% of Medicaid interim rate","90.00","75","","","Percent of Total Billed Charges","neg_dollar:$90","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","68.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.39;103.5% of Medicaid interim rate","120.00","150","","","Percent of Total Billed Charges","neg_dollar:$185.52;150% of Medicaid interim rate","96.00","80","","","Percent of Total Billed Charges","neg_dollar:$96;Percent of Total Billed Charges","110.40","92","","","Percent of Total Billed Charges","neg_dollar:$110.40","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","120.00",""
"ADMIN HEPATITIS B VACCINE","90471","CPT","90000611","CDM","771","RC","","Facility","Outpatient","","","120","96.00","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","70.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$70.49;102% of Medicaid interim rate","90.00","75","","","Percent of Total Billed Charges","neg_dollar:$90","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","68.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.39;103.5% of Medicaid interim rate","120.00","150","","","Percent of Total Billed Charges","neg_dollar:$185.52;150% of Medicaid interim rate","96.00","80","","","Percent of Total Billed Charges","neg_dollar:$96;Percent of Total Billed Charges","110.40","92","","","Percent of Total Billed Charges","neg_dollar:$110.40","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","120.00",""
"INFLUENZA VIRUS VACC SPLIT PF 0.5 ML IM SUSY","90471","CPT","19515-810-41","NDC","771","RC","","Facility","Outpatient","1","EA","114","114.00","114.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","114.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","98.03","86","","","Percent of Total Billed Charges","neg_dollar:$98.03","79.80","70","","","Percent of Total Billed Charges","neg_dollar:$79.80","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","66.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.97;102% of Medicaid interim rate","85.50","75","","","Percent of Total Billed Charges","neg_dollar:$85.50","98.03","86","","","Percent of Total Billed Charges","neg_dollar:$98.03","79.80","70","","","Percent of Total Billed Charges","neg_dollar:$79.80","64.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.97;103.5% of Medicaid interim rate","114.00","150","","","Percent of Total Billed Charges","neg_dollar:$176.24;150% of Medicaid interim rate","91.20","80","","","Percent of Total Billed Charges","neg_dollar:$91.20;Percent of Total Billed Charges","104.88","92","","","Percent of Total Billed Charges","neg_dollar:$104.88","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","59.00","114.00",""
"IMMUNIZATION ADM EA ADDTL VACCINE","90472","CPT","90000002","CDM","771","RC","","Facility","Outpatient","","","114","91.20","114.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","114.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","98.03","86","","","Percent of Total Billed Charges","neg_dollar:$98.03","79.80","70","","","Percent of Total Billed Charges","neg_dollar:$79.80","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","66.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.97;102% of Medicaid interim rate","85.50","75","","","Percent of Total Billed Charges","neg_dollar:$85.50","98.03","86","","","Percent of Total Billed Charges","neg_dollar:$98.03","79.80","70","","","Percent of Total Billed Charges","neg_dollar:$79.80","64.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.97;103.5% of Medicaid interim rate","114.00","150","","","Percent of Total Billed Charges","neg_dollar:$176.24;150% of Medicaid interim rate","91.20","80","","","Percent of Total Billed Charges","neg_dollar:$91.20;Percent of Total Billed Charges","104.88","92","","","Percent of Total Billed Charges","neg_dollar:$104.88","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","59.28","52","","","Percent of Total Billed Charges","neg_dollar:$59.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","59.00","114.00",""
"ADMN SARSCOV2 VACC 1 DOSE","90480","CPT","90001456","CDM","771","RC","","Facility","Outpatient","","","56","44.80","56.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","29.12","52","","","Percent of Total Billed Charges","neg_dollar:$29.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","56.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","29.12","52","","","Percent of Total Billed Charges","neg_dollar:$29.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","29.12","52","","","Percent of Total Billed Charges","neg_dollar:$29.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","29.12","52","","","Percent of Total Billed Charges","neg_dollar:$29.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","48.16","86","","","Percent of Total Billed Charges","neg_dollar:$48.16","39.19","70","","","Percent of Total Billed Charges","neg_dollar:$39.19","29.12","52","","","Percent of Total Billed Charges","neg_dollar:$29.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","32.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.89;102% of Medicaid interim rate","42.00","75","","","Percent of Total Billed Charges","neg_dollar:$42","48.16","86","","","Percent of Total Billed Charges","neg_dollar:$48.16","39.19","70","","","Percent of Total Billed Charges","neg_dollar:$39.19","31.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.91;103.5% of Medicaid interim rate","56.00","150","","","Percent of Total Billed Charges","neg_dollar:$86.57;150% of Medicaid interim rate","44.80","80","","","Percent of Total Billed Charges","neg_dollar:$44.80;Percent of Total Billed Charges","51.52","92","","","Percent of Total Billed Charges","neg_dollar:$51.52","29.12","52","","","Percent of Total Billed Charges","neg_dollar:$29.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","29.12","52","","","Percent of Total Billed Charges","neg_dollar:$29.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","29.00","56.00",""
"INFLUENZA VIRUS VACC SPLIT PF 0.5 ML IM SUSY","90656","CPT","19515-810-41","NDC","636","RC","","Facility","Outpatient","1","EA","127","127.00","","","","127.00","Fee Schedule","","","","","127.00","Fee Schedule","101% of Medicare Fee Schedule","","","","127.00","Fee Schedule","","66.04","52","","","Percent of Total Billed Charges","neg_dollar:$66.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","127.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","127.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","109.22","86","","","Percent of Total Billed Charges","neg_dollar:$109.22","88.89","70","","","Percent of Total Billed Charges","neg_dollar:$88.89","66.04","52","","","Percent of Total Billed Charges","neg_dollar:$66.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","74.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$74.61;102% of Medicaid interim rate","95.25","75","","","Percent of Total Billed Charges","neg_dollar:$95.25","109.22","86","","","Percent of Total Billed Charges","neg_dollar:$109.22","88.89","70","","","Percent of Total Billed Charges","neg_dollar:$88.89","72.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$72.39;103.5% of Medicaid interim rate","127.00","150","","","Percent of Total Billed Charges","neg_dollar:$196.34;150% of Medicaid interim rate","101.60","80","","","Percent of Total Billed Charges","neg_dollar:$101.60;Percent of Total Billed Charges","116.84","92","","","Percent of Total Billed Charges","neg_dollar:$116.84","66.04","52","","","Percent of Total Billed Charges","neg_dollar:$66.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","66.04","52","","","Percent of Total Billed Charges","neg_dollar:$66.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","66.00","127.00",""
"RABIES VACCINE, PCEC IM SUSR","90675","CPT","50632-010-01","NDC","636","RC","","Facility","Outpatient","1","EA","939","939.00","","","","310.00","Fee Schedule","","","","","431.00","Fee Schedule","101% of Medicare Fee Schedule","","","","294.00","Fee Schedule","","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","939.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","939.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","807.54","86","","","Percent of Total Billed Charges","neg_dollar:$807.54","657.30","70","","","Percent of Total Billed Charges","neg_dollar:$657.30","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","551.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$551.66;102% of Medicaid interim rate","704.25","75","","","Percent of Total Billed Charges","neg_dollar:$704.25","807.54","86","","","Percent of Total Billed Charges","neg_dollar:$807.54","657.30","70","","","Percent of Total Billed Charges","neg_dollar:$657.30","535.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$535.23;103.5% of Medicaid interim rate","939.00","150","","","Percent of Total Billed Charges","neg_dollar:$1451.75;150% of Medicaid interim rate","751.20","80","","","Percent of Total Billed Charges","neg_dollar:$751.20;Percent of Total Billed Charges","863.88","92","","","Percent of Total Billed Charges","neg_dollar:$863.88","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","294.00","939.00",""
"RABIES VACCINE, PCEC IM SUSR","90675","CPT","50632-013-01","NDC","636","RC","","Facility","Outpatient","1","EA","915.35","915.35","","","","310.00","Fee Schedule","","","","","431.00","Fee Schedule","101% of Medicare Fee Schedule","","","","294.00","Fee Schedule","","475.98","52","","","Percent of Total Billed Charges","neg_dollar:$475.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","915.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","915.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","787.20","86","","","Percent of Total Billed Charges","neg_dollar:$787.20","640.74","70","","","Percent of Total Billed Charges","neg_dollar:$640.74","475.98","52","","","Percent of Total Billed Charges","neg_dollar:$475.98;105% Medicare Outpatient Cost to Charge Ratio of 52%","537.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$537.76;102% of Medicaid interim rate","686.51","75","","","Percent of Total Billed Charges","neg_dollar:$686.51","787.20","86","","","Percent of Total Billed Charges","neg_dollar:$787.20","640.74","70","","","Percent of Total Billed Charges","neg_dollar:$640.74","521.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$521.74;103.5% of Medicaid interim rate","915.35","150","","","Percent of Total Billed Charges","neg_dollar:$1415.17;150% of Medicaid interim rate","732.28","80","","","Percent of Total Billed Charges","neg_dollar:$732.28;Percent of Total Billed Charges","842.12","92","","","Percent of Total Billed Charges","neg_dollar:$842.12","475.98","52","","","Percent of Total Billed Charges","neg_dollar:$475.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","475.98","52","","","Percent of Total Billed Charges","neg_dollar:$475.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","294.00","915.00",""
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY","90715","CPT","58160-842-52","NDC","636","RC","","Facility","Outpatient","1","EA","182.30","182.30","","","","38.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","38.00","Fee Schedule","","94.79","52","","","Percent of Total Billed Charges","neg_dollar:$94.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","156.77","86","","","Percent of Total Billed Charges","neg_dollar:$156.77","127.61","70","","","Percent of Total Billed Charges","neg_dollar:$127.61","94.79","52","","","Percent of Total Billed Charges","neg_dollar:$94.79;105% Medicare Outpatient Cost to Charge Ratio of 52%","107.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$107.10;102% of Medicaid interim rate","136.72","75","","","Percent of Total Billed Charges","neg_dollar:$136.72","156.77","86","","","Percent of Total Billed Charges","neg_dollar:$156.77","127.61","70","","","Percent of Total Billed Charges","neg_dollar:$127.61","103.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$103.91;103.5% of Medicaid interim rate","182.30","150","","","Percent of Total Billed Charges","neg_dollar:$281.84;150% of Medicaid interim rate","145.84","80","","","Percent of Total Billed Charges","neg_dollar:$145.84;Percent of Total Billed Charges","167.71","92","","","Percent of Total Billed Charges","neg_dollar:$167.71","94.79","52","","","Percent of Total Billed Charges","neg_dollar:$94.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.79","52","","","Percent of Total Billed Charges","neg_dollar:$94.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","38.00","182.00",""
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY","90715","CPT","58160-842-52","NDC","636","RC","","Facility","Outpatient","1","EA","182.49","182.49","","","","38.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","38.00","Fee Schedule","","94.89","52","","","Percent of Total Billed Charges","neg_dollar:$94.89;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.49","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.49","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","156.94","86","","","Percent of Total Billed Charges","neg_dollar:$156.94","127.74","70","","","Percent of Total Billed Charges","neg_dollar:$127.74","94.89","52","","","Percent of Total Billed Charges","neg_dollar:$94.89;105% Medicare Outpatient Cost to Charge Ratio of 52%","107.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$107.21;102% of Medicaid interim rate","136.87","75","","","Percent of Total Billed Charges","neg_dollar:$136.87","156.94","86","","","Percent of Total Billed Charges","neg_dollar:$156.94","127.74","70","","","Percent of Total Billed Charges","neg_dollar:$127.74","104.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$104.02;103.5% of Medicaid interim rate","182.49","150","","","Percent of Total Billed Charges","neg_dollar:$282.15;150% of Medicaid interim rate","145.99","80","","","Percent of Total Billed Charges","neg_dollar:$145.99;Percent of Total Billed Charges","167.89","92","","","Percent of Total Billed Charges","neg_dollar:$167.89","94.89","52","","","Percent of Total Billed Charges","neg_dollar:$94.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.89","52","","","Percent of Total Billed Charges","neg_dollar:$94.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","38.00","182.00",""
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSY","90715","CPT","58160-842-43","NDC","636","RC","","Facility","Outpatient","1","EA","182.30","182.30","","","","38.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","38.00","Fee Schedule","","94.79","52","","","Percent of Total Billed Charges","neg_dollar:$94.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","156.77","86","","","Percent of Total Billed Charges","neg_dollar:$156.77","127.61","70","","","Percent of Total Billed Charges","neg_dollar:$127.61","94.79","52","","","Percent of Total Billed Charges","neg_dollar:$94.79;105% Medicare Outpatient Cost to Charge Ratio of 52%","107.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$107.10;102% of Medicaid interim rate","136.72","75","","","Percent of Total Billed Charges","neg_dollar:$136.72","156.77","86","","","Percent of Total Billed Charges","neg_dollar:$156.77","127.61","70","","","Percent of Total Billed Charges","neg_dollar:$127.61","103.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$103.91;103.5% of Medicaid interim rate","182.30","150","","","Percent of Total Billed Charges","neg_dollar:$281.84;150% of Medicaid interim rate","145.84","80","","","Percent of Total Billed Charges","neg_dollar:$145.84;Percent of Total Billed Charges","167.71","92","","","Percent of Total Billed Charges","neg_dollar:$167.71","94.79","52","","","Percent of Total Billed Charges","neg_dollar:$94.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.79","52","","","Percent of Total Billed Charges","neg_dollar:$94.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","38.00","182.00",""
"HEP B VACC ADULT 3 DOSE IM","90746","CPT","90000209","CDM","636","RC","","Facility","Outpatient","","","219","175.20","","","","219.00","Fee Schedule","","","","","219.00","Fee Schedule","101% of Medicare Fee Schedule","","","","219.00","Fee Schedule","","113.88","52","","","Percent of Total Billed Charges","neg_dollar:$113.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","219.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","219.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","188.34","86","","","Percent of Total Billed Charges","neg_dollar:$188.34","153.29","70","","","Percent of Total Billed Charges","neg_dollar:$153.29","113.88","52","","","Percent of Total Billed Charges","neg_dollar:$113.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","128.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$128.66;102% of Medicaid interim rate","164.25","75","","","Percent of Total Billed Charges","neg_dollar:$164.25","188.34","86","","","Percent of Total Billed Charges","neg_dollar:$188.34","153.29","70","","","Percent of Total Billed Charges","neg_dollar:$153.29","124.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$124.82;103.5% of Medicaid interim rate","219.00","150","","","Percent of Total Billed Charges","neg_dollar:$338.58;150% of Medicaid interim rate","175.20","80","","","Percent of Total Billed Charges","neg_dollar:$175.20;Percent of Total Billed Charges","201.48","92","","","Percent of Total Billed Charges","neg_dollar:$201.48","113.88","52","","","Percent of Total Billed Charges","neg_dollar:$113.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","113.88","52","","","Percent of Total Billed Charges","neg_dollar:$113.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","113.00","219.00",""
"PSYCH DIAGNOSTIC EVALUATION","90791","CPT","90000711","CDM","900","RC","","Facility","Outpatient","","","384","307.20","384.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","199.68","52","","","Percent of Total Billed Charges","neg_dollar:$199.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","384.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","199.68","52","","","Percent of Total Billed Charges","neg_dollar:$199.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","199.68","52","","","Percent of Total Billed Charges","neg_dollar:$199.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","199.68","52","","","Percent of Total Billed Charges","neg_dollar:$199.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","330.24","86","","","Percent of Total Billed Charges","neg_dollar:$330.24","268.79","70","","","Percent of Total Billed Charges","neg_dollar:$268.79","199.68","52","","","Percent of Total Billed Charges","neg_dollar:$199.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","225.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$225.59;102% of Medicaid interim rate","288.00","75","","","Percent of Total Billed Charges","neg_dollar:$288","330.24","86","","","Percent of Total Billed Charges","neg_dollar:$330.24","268.79","70","","","Percent of Total Billed Charges","neg_dollar:$268.79","218.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$218.88;103.5% of Medicaid interim rate","384.00","150","","","Percent of Total Billed Charges","neg_dollar:$593.68;150% of Medicaid interim rate","307.20","80","","","Percent of Total Billed Charges","neg_dollar:$307.20;Percent of Total Billed Charges","353.28","92","","","Percent of Total Billed Charges","neg_dollar:$353.28","199.68","52","","","Percent of Total Billed Charges","neg_dollar:$199.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","199.68","52","","","Percent of Total Billed Charges","neg_dollar:$199.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","199.00","384.00",""
"PSYTX W PT 30 MIN (16-37 MIN)","90832","CPT","90000713","CDM","900","RC","","Facility","Outpatient","","","161","128.80","161.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","161.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","138.46","86","","","Percent of Total Billed Charges","neg_dollar:$138.46","112.69","70","","","Percent of Total Billed Charges","neg_dollar:$112.69","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","94.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$94.58;102% of Medicaid interim rate","120.75","75","","","Percent of Total Billed Charges","neg_dollar:$120.75","138.46","86","","","Percent of Total Billed Charges","neg_dollar:$138.46","112.69","70","","","Percent of Total Billed Charges","neg_dollar:$112.69","91.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$91.77;103.5% of Medicaid interim rate","161.00","150","","","Percent of Total Billed Charges","neg_dollar:$248.91;150% of Medicaid interim rate","128.80","80","","","Percent of Total Billed Charges","neg_dollar:$128.80;Percent of Total Billed Charges","148.12","92","","","Percent of Total Billed Charges","neg_dollar:$148.12","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","83.00","161.00",""
"PSYTX W PT 45 MIN (38-52 MIN)","90834","CPT","90000715","CDM","900","RC","","Facility","Outpatient","","","245","196.00","245.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","127.40","52","","","Percent of Total Billed Charges","neg_dollar:$127.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","245.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","127.40","52","","","Percent of Total Billed Charges","neg_dollar:$127.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","127.40","52","","","Percent of Total Billed Charges","neg_dollar:$127.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","127.40","52","","","Percent of Total Billed Charges","neg_dollar:$127.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","210.70","86","","","Percent of Total Billed Charges","neg_dollar:$210.70","171.50","70","","","Percent of Total Billed Charges","neg_dollar:$171.50","127.40","52","","","Percent of Total Billed Charges","neg_dollar:$127.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","143.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$143.93;102% of Medicaid interim rate","183.75","75","","","Percent of Total Billed Charges","neg_dollar:$183.75","210.70","86","","","Percent of Total Billed Charges","neg_dollar:$210.70","171.50","70","","","Percent of Total Billed Charges","neg_dollar:$171.50","139.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$139.64;103.5% of Medicaid interim rate","245.00","150","","","Percent of Total Billed Charges","neg_dollar:$378.78;150% of Medicaid interim rate","196.00","80","","","Percent of Total Billed Charges","neg_dollar:$196;Percent of Total Billed Charges","225.40","92","","","Percent of Total Billed Charges","neg_dollar:$225.40","127.40","52","","","Percent of Total Billed Charges","neg_dollar:$127.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","127.40","52","","","Percent of Total Billed Charges","neg_dollar:$127.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","127.00","245.00",""
"PSYTX W PT 60 MIN (>53 MIN)","90837","CPT","90000717","CDM","900","RC","","Facility","Outpatient","","","365","292.00","365.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","365.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","313.90","86","","","Percent of Total Billed Charges","neg_dollar:$313.90","255.49","70","","","Percent of Total Billed Charges","neg_dollar:$255.49","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","214.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$214.43;102% of Medicaid interim rate","273.75","75","","","Percent of Total Billed Charges","neg_dollar:$273.75","313.90","86","","","Percent of Total Billed Charges","neg_dollar:$313.90","255.49","70","","","Percent of Total Billed Charges","neg_dollar:$255.49","208.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$208.04;103.5% of Medicaid interim rate","365.00","150","","","Percent of Total Billed Charges","neg_dollar:$564.30;150% of Medicaid interim rate","292.00","80","","","Percent of Total Billed Charges","neg_dollar:$292;Percent of Total Billed Charges","335.80","92","","","Percent of Total Billed Charges","neg_dollar:$335.80","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","189.00","365.00",""
"FAMILY THERAPY W PT 50 MIN","90847","CPT","90000503","CDM","916","RC","","Facility","Outpatient","","","292","233.60","292.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","292.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","251.12","86","","","Percent of Total Billed Charges","neg_dollar:$251.12","204.39","70","","","Percent of Total Billed Charges","neg_dollar:$204.39","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","171.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$171.54;102% of Medicaid interim rate","219.00","75","","","Percent of Total Billed Charges","neg_dollar:$219","251.12","86","","","Percent of Total Billed Charges","neg_dollar:$251.12","204.39","70","","","Percent of Total Billed Charges","neg_dollar:$204.39","166.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$166.44;103.5% of Medicaid interim rate","292.00","150","","","Percent of Total Billed Charges","neg_dollar:$451.44;150% of Medicaid interim rate","233.60","80","","","Percent of Total Billed Charges","neg_dollar:$233.60;Percent of Total Billed Charges","268.64","92","","","Percent of Total Billed Charges","neg_dollar:$268.64","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","151.84","52","","","Percent of Total Billed Charges","neg_dollar:$151.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","151.00","292.00",""
"SARSCOV2 VAC 50 MCG/0.5ML IM","91322","CPT","25001270","CDM","636","RC","","Facility","Outpatient","","","424","339.20","","","","424.00","Fee Schedule","","","","","424.00","Fee Schedule","101% of Medicare Fee Schedule","","","","424.00","Fee Schedule","","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","424.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","424.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","249.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.09;102% of Medicaid interim rate","318.00","75","","","Percent of Total Billed Charges","neg_dollar:$318","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","241.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$241.67;103.5% of Medicaid interim rate","424.00","150","","","Percent of Total Billed Charges","neg_dollar:$655.52;150% of Medicaid interim rate","339.20","80","","","Percent of Total Billed Charges","neg_dollar:$339.20;Percent of Total Billed Charges","390.08","92","","","Percent of Total Billed Charges","neg_dollar:$390.08","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.00","424.00",""
"SPEECH/HEARING THERAPY","92507","CPT","97000053","CDM","440","RC","","Facility","Outpatient","","","253","202.40","253.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","253.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","217.57","86","","","Percent of Total Billed Charges","neg_dollar:$217.57","177.10","70","","","Percent of Total Billed Charges","neg_dollar:$177.10","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","148.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$148.63;102% of Medicaid interim rate","189.75","75","","","Percent of Total Billed Charges","neg_dollar:$189.75","217.57","86","","","Percent of Total Billed Charges","neg_dollar:$217.57","177.10","70","","","Percent of Total Billed Charges","neg_dollar:$177.10","144.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$144.20;103.5% of Medicaid interim rate","253.00","150","","","Percent of Total Billed Charges","neg_dollar:$391.15;150% of Medicaid interim rate","202.40","80","","","Percent of Total Billed Charges","neg_dollar:$202.40;Percent of Total Billed Charges","232.76","92","","","Percent of Total Billed Charges","neg_dollar:$232.76","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","131.00","253.00",""
"EVALUATE SPEECH FLUENCY","92521","CPT","97000272","CDM","440","RC","","Facility","Outpatient","","","324","259.20","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","190.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$190.34;102% of Medicaid interim rate","243.00","75","","","Percent of Total Billed Charges","neg_dollar:$243","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","184.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$184.67;103.5% of Medicaid interim rate","324.00","150","","","Percent of Total Billed Charges","neg_dollar:$500.92;150% of Medicaid interim rate","259.20","80","","","Percent of Total Billed Charges","neg_dollar:$259.20;Percent of Total Billed Charges","298.08","92","","","Percent of Total Billed Charges","neg_dollar:$298.08","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.00","324.00",""
"EVALUATE SPEECH PRODUCTION","92522","CPT","97000273","CDM","440","RC","","Facility","Outpatient","","","324","259.20","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","190.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$190.34;102% of Medicaid interim rate","243.00","75","","","Percent of Total Billed Charges","neg_dollar:$243","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","184.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$184.67;103.5% of Medicaid interim rate","324.00","150","","","Percent of Total Billed Charges","neg_dollar:$500.92;150% of Medicaid interim rate","259.20","80","","","Percent of Total Billed Charges","neg_dollar:$259.20;Percent of Total Billed Charges","298.08","92","","","Percent of Total Billed Charges","neg_dollar:$298.08","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.00","324.00",""
"EVAL SPEECH SOUND LANG COMPREHEN","92523","CPT","97000274","CDM","440","RC","","Facility","Outpatient","","","324","259.20","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","190.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$190.34;102% of Medicaid interim rate","243.00","75","","","Percent of Total Billed Charges","neg_dollar:$243","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","184.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$184.67;103.5% of Medicaid interim rate","324.00","150","","","Percent of Total Billed Charges","neg_dollar:$500.92;150% of Medicaid interim rate","259.20","80","","","Percent of Total Billed Charges","neg_dollar:$259.20;Percent of Total Billed Charges","298.08","92","","","Percent of Total Billed Charges","neg_dollar:$298.08","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.00","324.00",""
"BEHAVIORAL QUAL ANALYSIS VOICE","92524","CPT","97000275","CDM","440","RC","","Facility","Outpatient","","","324","259.20","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","190.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$190.34;102% of Medicaid interim rate","243.00","75","","","Percent of Total Billed Charges","neg_dollar:$243","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","184.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$184.67;103.5% of Medicaid interim rate","324.00","150","","","Percent of Total Billed Charges","neg_dollar:$500.92;150% of Medicaid interim rate","259.20","80","","","Percent of Total Billed Charges","neg_dollar:$259.20;Percent of Total Billed Charges","298.08","92","","","Percent of Total Billed Charges","neg_dollar:$298.08","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.00","324.00",""
"TREAT SWALLOWING DYSFUNCTION","92526","CPT","97000055","CDM","440","RC","","Facility","Outpatient","","","248","198.40","248.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","248.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","213.28","86","","","Percent of Total Billed Charges","neg_dollar:$213.28","173.60","70","","","Percent of Total Billed Charges","neg_dollar:$173.60","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","145.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$145.69;102% of Medicaid interim rate","186.00","75","","","Percent of Total Billed Charges","neg_dollar:$186","213.28","86","","","Percent of Total Billed Charges","neg_dollar:$213.28","173.60","70","","","Percent of Total Billed Charges","neg_dollar:$173.60","141.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$141.35;103.5% of Medicaid interim rate","248.00","150","","","Percent of Total Billed Charges","neg_dollar:$383.42;150% of Medicaid interim rate","198.40","80","","","Percent of Total Billed Charges","neg_dollar:$198.40;Percent of Total Billed Charges","228.16","92","","","Percent of Total Billed Charges","neg_dollar:$228.16","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","128.96","52","","","Percent of Total Billed Charges","neg_dollar:$128.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","128.00","248.00",""
"EVAL FOR SPEECH DEVICE RX 1HR","92607","CPT","97000058","CDM","440","RC","","Facility","Outpatient","","","424","339.20","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","249.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.09;102% of Medicaid interim rate","318.00","75","","","Percent of Total Billed Charges","neg_dollar:$318","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","241.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$241.67;103.5% of Medicaid interim rate","424.00","150","","","Percent of Total Billed Charges","neg_dollar:$655.52;150% of Medicaid interim rate","339.20","80","","","Percent of Total Billed Charges","neg_dollar:$339.20;Percent of Total Billed Charges","390.08","92","","","Percent of Total Billed Charges","neg_dollar:$390.08","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.00","424.00",""
"EX FOR SPEECH DEVICE RX ADDL 30M","92608","CPT","97000059","CDM","440","RC","","Facility","Outpatient","","","213","170.40","213.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","213.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","183.18","86","","","Percent of Total Billed Charges","neg_dollar:$183.18","149.10","70","","","Percent of Total Billed Charges","neg_dollar:$149.10","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","125.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$125.13;102% of Medicaid interim rate","159.75","75","","","Percent of Total Billed Charges","neg_dollar:$159.75","183.18","86","","","Percent of Total Billed Charges","neg_dollar:$183.18","149.10","70","","","Percent of Total Billed Charges","neg_dollar:$149.10","121.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$121.41;103.5% of Medicaid interim rate","213.00","150","","","Percent of Total Billed Charges","neg_dollar:$329.30;150% of Medicaid interim rate","170.40","80","","","Percent of Total Billed Charges","neg_dollar:$170.40;Percent of Total Billed Charges","195.96","92","","","Percent of Total Billed Charges","neg_dollar:$195.96","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","110.00","213.00",""
"EVALUATE SWALLOWING FUNCTION","92610","CPT","97000061","CDM","440","RC","","Facility","Outpatient","","","424","339.20","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","249.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.09;102% of Medicaid interim rate","318.00","75","","","Percent of Total Billed Charges","neg_dollar:$318","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","241.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$241.67;103.5% of Medicaid interim rate","424.00","150","","","Percent of Total Billed Charges","neg_dollar:$655.52;150% of Medicaid interim rate","339.20","80","","","Percent of Total Billed Charges","neg_dollar:$339.20;Percent of Total Billed Charges","390.08","92","","","Percent of Total Billed Charges","neg_dollar:$390.08","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.00","424.00",""
"MOTION FLUORO SWALLOW FCN","92611","CPT","97000062","CDM","440","RC","","Facility","Outpatient","","","494","395.20","494.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","494.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","424.84","86","","","Percent of Total Billed Charges","neg_dollar:$424.84","345.79","70","","","Percent of Total Billed Charges","neg_dollar:$345.79","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","290.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$290.22;102% of Medicaid interim rate","370.50","75","","","Percent of Total Billed Charges","neg_dollar:$370.50","424.84","86","","","Percent of Total Billed Charges","neg_dollar:$424.84","345.79","70","","","Percent of Total Billed Charges","neg_dollar:$345.79","281.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$281.58;103.5% of Medicaid interim rate","494.00","150","","","Percent of Total Billed Charges","neg_dollar:$763.74;150% of Medicaid interim rate","395.20","80","","","Percent of Total Billed Charges","neg_dollar:$395.20;Percent of Total Billed Charges","454.48","92","","","Percent of Total Billed Charges","neg_dollar:$454.48","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","256.88","52","","","Percent of Total Billed Charges","neg_dollar:$256.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","256.00","494.00",""
"ENDOSCOPY SWALLOW (FEES) VID","92612","CPT","97000276","CDM","440","RC","","Facility","Outpatient","","","882","705.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","758.52","86","","","Percent of Total Billed Charges","neg_dollar:$758.52","617.40","70","","","Percent of Total Billed Charges","neg_dollar:$617.40","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","518.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$518.17;102% of Medicaid interim rate","661.50","75","","","Percent of Total Billed Charges","neg_dollar:$661.50","758.52","86","","","Percent of Total Billed Charges","neg_dollar:$758.52","617.40","70","","","Percent of Total Billed Charges","neg_dollar:$617.40","502.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$502.73;103.5% of Medicaid interim rate","882.00","150","","","Percent of Total Billed Charges","neg_dollar:$1363.61;150% of Medicaid interim rate","705.60","80","","","Percent of Total Billed Charges","neg_dollar:$705.60;Percent of Total Billed Charges","811.44","92","","","Percent of Total Billed Charges","neg_dollar:$811.44","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","458.00","882.00",""
"CPR","92950","CPT","90000100","CDM","480","RC","","Facility","Outpatient","","","1050","840.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","546.00","52","","","Percent of Total Billed Charges","neg_dollar:$546;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","546.00","52","","","Percent of Total Billed Charges","neg_dollar:$546;102% Medicare Outpatient Cost to Charge Ratio of 52%","546.00","52","","","Percent of Total Billed Charges","neg_dollar:$546;102% Medicare Outpatient Cost to Charge Ratio of 52%","546.00","52","","","Percent of Total Billed Charges","neg_dollar:$546;102% Medicare Outpatient Cost to Charge Ratio of 52%","903.00","86","","","Percent of Total Billed Charges","neg_dollar:$903","735.00","70","","","Percent of Total Billed Charges","neg_dollar:$735","546.00","52","","","Percent of Total Billed Charges","neg_dollar:$546;105% Medicare Outpatient Cost to Charge Ratio of 52%","616.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$616.87;102% of Medicaid interim rate","787.50","75","","","Percent of Total Billed Charges","neg_dollar:$787.50","903.00","86","","","Percent of Total Billed Charges","neg_dollar:$903","735.00","70","","","Percent of Total Billed Charges","neg_dollar:$735","598.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$598.50;103.5% of Medicaid interim rate","1050.00","150","","","Percent of Total Billed Charges","neg_dollar:$1623.35;150% of Medicaid interim rate","840.00","80","","","Percent of Total Billed Charges","neg_dollar:$840;Percent of Total Billed Charges","966.00","92","","","Percent of Total Billed Charges","neg_dollar:$966","546.00","52","","","Percent of Total Billed Charges","neg_dollar:$546;100% Medicare Outpatient Cost to Charge Ratio of 52%","546.00","52","","","Percent of Total Billed Charges","neg_dollar:$546;100% Medicare Outpatient Cost to Charge Ratio of 52%","546.00","1050.00",""
"TEMP TRANSCUTAN PACING","92953","CPT","90000020","CDM","480","RC","","Facility","Outpatient","","","38","30.40","38.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","38.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.68","86","","","Percent of Total Billed Charges","neg_dollar:$32.68","26.59","70","","","Percent of Total Billed Charges","neg_dollar:$26.59","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","22.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.32;102% of Medicaid interim rate","28.50","75","","","Percent of Total Billed Charges","neg_dollar:$28.50","32.68","86","","","Percent of Total Billed Charges","neg_dollar:$32.68","26.59","70","","","Percent of Total Billed Charges","neg_dollar:$26.59","21.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.65;103.5% of Medicaid interim rate","38.00","150","","","Percent of Total Billed Charges","neg_dollar:$58.74;150% of Medicaid interim rate","30.40","80","","","Percent of Total Billed Charges","neg_dollar:$30.40;Percent of Total Billed Charges","34.96","92","","","Percent of Total Billed Charges","neg_dollar:$34.96","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","19.00","38.00",""
"CARDIOVERSION","92960","CPT","90000101","CDM","480","RC","","Facility","Outpatient","","","1218","974.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","633.36","52","","","Percent of Total Billed Charges","neg_dollar:$633.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","633.36","52","","","Percent of Total Billed Charges","neg_dollar:$633.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","633.36","52","","","Percent of Total Billed Charges","neg_dollar:$633.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","633.36","52","","","Percent of Total Billed Charges","neg_dollar:$633.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1047.48","86","","","Percent of Total Billed Charges","neg_dollar:$1047.48","852.59","70","","","Percent of Total Billed Charges","neg_dollar:$852.59","633.36","52","","","Percent of Total Billed Charges","neg_dollar:$633.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","715.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$715.57;102% of Medicaid interim rate","913.50","75","","","Percent of Total Billed Charges","neg_dollar:$913.50","1047.48","86","","","Percent of Total Billed Charges","neg_dollar:$1047.48","852.59","70","","","Percent of Total Billed Charges","neg_dollar:$852.59","694.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$694.26;103.5% of Medicaid interim rate","1218.00","150","","","Percent of Total Billed Charges","neg_dollar:$1883.08;150% of Medicaid interim rate","974.40","80","","","Percent of Total Billed Charges","neg_dollar:$974.40;Percent of Total Billed Charges","1120.56","92","","","Percent of Total Billed Charges","neg_dollar:$1120.56","633.36","52","","","Percent of Total Billed Charges","neg_dollar:$633.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","633.36","52","","","Percent of Total Billed Charges","neg_dollar:$633.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","633.00","1218.00",""
"THROMBOLYSIS CORON IV INFUS","92977","CPT","90000679","CDM","360","RC","","Facility","Outpatient","","","679","543.20","679.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","353.08","52","","","Percent of Total Billed Charges","neg_dollar:$353.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","679.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","353.08","52","","","Percent of Total Billed Charges","neg_dollar:$353.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","353.08","52","","","Percent of Total Billed Charges","neg_dollar:$353.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","353.08","52","","","Percent of Total Billed Charges","neg_dollar:$353.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","583.93","86","","","Percent of Total Billed Charges","neg_dollar:$583.93","475.29","70","","","Percent of Total Billed Charges","neg_dollar:$475.29","353.08","52","","","Percent of Total Billed Charges","neg_dollar:$353.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","398.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$398.91;102% of Medicaid interim rate","509.25","75","","","Percent of Total Billed Charges","neg_dollar:$509.25","583.93","86","","","Percent of Total Billed Charges","neg_dollar:$583.93","475.29","70","","","Percent of Total Billed Charges","neg_dollar:$475.29","387.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$387.03;103.5% of Medicaid interim rate","679.00","150","","","Percent of Total Billed Charges","neg_dollar:$1049.76;150% of Medicaid interim rate","543.20","80","","","Percent of Total Billed Charges","neg_dollar:$543.20;Percent of Total Billed Charges","624.68","92","","","Percent of Total Billed Charges","neg_dollar:$624.68","353.08","52","","","Percent of Total Billed Charges","neg_dollar:$353.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","353.08","52","","","Percent of Total Billed Charges","neg_dollar:$353.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","353.00","679.00",""
"12 LEAD EKG; TRACING ONLY","93005","CPT","90000210","CDM","730","RC","","Facility","Outpatient","","","270","216.00","270.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","270.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","232.20","86","","","Percent of Total Billed Charges","neg_dollar:$232.20","189.00","70","","","Percent of Total Billed Charges","neg_dollar:$189","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","158.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$158.62;102% of Medicaid interim rate","202.50","75","","","Percent of Total Billed Charges","neg_dollar:$202.50","232.20","86","","","Percent of Total Billed Charges","neg_dollar:$232.20","189.00","70","","","Percent of Total Billed Charges","neg_dollar:$189","153.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$153.89;103.5% of Medicaid interim rate","270.00","150","","","Percent of Total Billed Charges","neg_dollar:$417.43;150% of Medicaid interim rate","216.00","80","","","Percent of Total Billed Charges","neg_dollar:$216;Percent of Total Billed Charges","248.40","92","","","Percent of Total Billed Charges","neg_dollar:$248.40","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","140.00","270.00",""
"CVSLR STRESS TEST; TRACING","93017","CPT","90000290","CDM","482","RC","","Facility","Outpatient","","","863","690.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","448.76","52","","","Percent of Total Billed Charges","neg_dollar:$448.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","448.76","52","","","Percent of Total Billed Charges","neg_dollar:$448.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","448.76","52","","","Percent of Total Billed Charges","neg_dollar:$448.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","448.76","52","","","Percent of Total Billed Charges","neg_dollar:$448.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","742.18","86","","","Percent of Total Billed Charges","neg_dollar:$742.18","604.09","70","","","Percent of Total Billed Charges","neg_dollar:$604.09","448.76","52","","","Percent of Total Billed Charges","neg_dollar:$448.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","507.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$507.01;102% of Medicaid interim rate","647.25","75","","","Percent of Total Billed Charges","neg_dollar:$647.25","742.18","86","","","Percent of Total Billed Charges","neg_dollar:$742.18","604.09","70","","","Percent of Total Billed Charges","neg_dollar:$604.09","491.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$491.90;103.5% of Medicaid interim rate","863.00","150","","","Percent of Total Billed Charges","neg_dollar:$1334.24;150% of Medicaid interim rate","690.40","80","","","Percent of Total Billed Charges","neg_dollar:$690.40;Percent of Total Billed Charges","793.96","92","","","Percent of Total Billed Charges","neg_dollar:$793.96","448.76","52","","","Percent of Total Billed Charges","neg_dollar:$448.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","448.76","52","","","Percent of Total Billed Charges","neg_dollar:$448.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","448.00","863.00",""
"1-3 LEAD EKG TRACING ONLY","93041","CPT","90000030","CDM","730","RC","","Facility","Outpatient","","","113","90.40","113.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","113.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","97.17","86","","","Percent of Total Billed Charges","neg_dollar:$97.17","79.10","70","","","Percent of Total Billed Charges","neg_dollar:$79.10","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","66.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.38;102% of Medicaid interim rate","84.75","75","","","Percent of Total Billed Charges","neg_dollar:$84.75","97.17","86","","","Percent of Total Billed Charges","neg_dollar:$97.17","79.10","70","","","Percent of Total Billed Charges","neg_dollar:$79.10","64.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.41;103.5% of Medicaid interim rate","113.00","150","","","Percent of Total Billed Charges","neg_dollar:$174.70;150% of Medicaid interim rate","90.40","80","","","Percent of Total Billed Charges","neg_dollar:$90.40;Percent of Total Billed Charges","103.96","92","","","Percent of Total Billed Charges","neg_dollar:$103.96","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.00","113.00",""
"ECG MONITOR 0-48 HRS RECORDING","93225","CPT","90000293","CDM","731","RC","","Facility","Outpatient","","","547","437.60","547.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","284.44","52","","","Percent of Total Billed Charges","neg_dollar:$284.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","547.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","284.44","52","","","Percent of Total Billed Charges","neg_dollar:$284.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","284.44","52","","","Percent of Total Billed Charges","neg_dollar:$284.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","284.44","52","","","Percent of Total Billed Charges","neg_dollar:$284.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","470.42","86","","","Percent of Total Billed Charges","neg_dollar:$470.42","382.90","70","","","Percent of Total Billed Charges","neg_dollar:$382.90","284.44","52","","","Percent of Total Billed Charges","neg_dollar:$284.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","321.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$321.36;102% of Medicaid interim rate","410.25","75","","","Percent of Total Billed Charges","neg_dollar:$410.25","470.42","86","","","Percent of Total Billed Charges","neg_dollar:$470.42","382.90","70","","","Percent of Total Billed Charges","neg_dollar:$382.90","311.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$311.78;103.5% of Medicaid interim rate","547.00","150","","","Percent of Total Billed Charges","neg_dollar:$845.68;150% of Medicaid interim rate","437.60","80","","","Percent of Total Billed Charges","neg_dollar:$437.60;Percent of Total Billed Charges","503.24","92","","","Percent of Total Billed Charges","neg_dollar:$503.24","284.44","52","","","Percent of Total Billed Charges","neg_dollar:$284.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","284.44","52","","","Percent of Total Billed Charges","neg_dollar:$284.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","284.00","547.00",""
"ECG 0-48 HRS SCANNING ANALYSIS REPORT","93226","CPT","90000296","CDM","731","RC","","Facility","Outpatient","","","774","619.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","774.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","665.64","86","","","Percent of Total Billed Charges","neg_dollar:$665.64","541.80","70","","","Percent of Total Billed Charges","neg_dollar:$541.80","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","454.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$454.72;102% of Medicaid interim rate","580.50","75","","","Percent of Total Billed Charges","neg_dollar:$580.50","665.64","86","","","Percent of Total Billed Charges","neg_dollar:$665.64","541.80","70","","","Percent of Total Billed Charges","neg_dollar:$541.80","441.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$441.17;103.5% of Medicaid interim rate","774.00","150","","","Percent of Total Billed Charges","neg_dollar:$1196.64;150% of Medicaid interim rate","619.20","80","","","Percent of Total Billed Charges","neg_dollar:$619.20;Percent of Total Billed Charges","712.08","92","","","Percent of Total Billed Charges","neg_dollar:$712.08","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","402.00","774.00",""
"EXT ECG 48HR TO 7 DAY RECORDING","93242","CPT","90001254","CDM","730","RC","","Facility","Outpatient","","","329","263.20","329.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","329.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","282.94","86","","","Percent of Total Billed Charges","neg_dollar:$282.94","230.29","70","","","Percent of Total Billed Charges","neg_dollar:$230.29","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","193.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$193.28;102% of Medicaid interim rate","246.75","75","","","Percent of Total Billed Charges","neg_dollar:$246.75","282.94","86","","","Percent of Total Billed Charges","neg_dollar:$282.94","230.29","70","","","Percent of Total Billed Charges","neg_dollar:$230.29","187.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$187.52;103.5% of Medicaid interim rate","329.00","150","","","Percent of Total Billed Charges","neg_dollar:$508.65;150% of Medicaid interim rate","263.20","80","","","Percent of Total Billed Charges","neg_dollar:$263.20;Percent of Total Billed Charges","302.68","92","","","Percent of Total Billed Charges","neg_dollar:$302.68","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","171.00","329.00",""
"EXT ECG 48HR TO 7 DAY SCAN W/ REPORT","93243","CPT","90001255","CDM","730","RC","","Facility","Outpatient","","","702","561.60","702.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","365.04","52","","","Percent of Total Billed Charges","neg_dollar:$365.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","702.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","365.04","52","","","Percent of Total Billed Charges","neg_dollar:$365.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","365.04","52","","","Percent of Total Billed Charges","neg_dollar:$365.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","365.04","52","","","Percent of Total Billed Charges","neg_dollar:$365.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","603.72","86","","","Percent of Total Billed Charges","neg_dollar:$603.72","491.40","70","","","Percent of Total Billed Charges","neg_dollar:$491.40","365.04","52","","","Percent of Total Billed Charges","neg_dollar:$365.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","412.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$412.42;102% of Medicaid interim rate","526.50","75","","","Percent of Total Billed Charges","neg_dollar:$526.50","603.72","86","","","Percent of Total Billed Charges","neg_dollar:$603.72","491.40","70","","","Percent of Total Billed Charges","neg_dollar:$491.40","400.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$400.14;103.5% of Medicaid interim rate","702.00","150","","","Percent of Total Billed Charges","neg_dollar:$1085.32;150% of Medicaid interim rate","561.60","80","","","Percent of Total Billed Charges","neg_dollar:$561.60;Percent of Total Billed Charges","645.84","92","","","Percent of Total Billed Charges","neg_dollar:$645.84","365.04","52","","","Percent of Total Billed Charges","neg_dollar:$365.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","365.04","52","","","Percent of Total Billed Charges","neg_dollar:$365.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","365.00","702.00",""
"EXT ECG 7 TO 15 DAY RECORDING","93246","CPT","90001256","CDM","730","RC","","Facility","Outpatient","","","313","250.40","313.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","313.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","269.18","86","","","Percent of Total Billed Charges","neg_dollar:$269.18","219.10","70","","","Percent of Total Billed Charges","neg_dollar:$219.10","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","183.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$183.88;102% of Medicaid interim rate","234.75","75","","","Percent of Total Billed Charges","neg_dollar:$234.75","269.18","86","","","Percent of Total Billed Charges","neg_dollar:$269.18","219.10","70","","","Percent of Total Billed Charges","neg_dollar:$219.10","178.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$178.41;103.5% of Medicaid interim rate","313.00","150","","","Percent of Total Billed Charges","neg_dollar:$483.91;150% of Medicaid interim rate","250.40","80","","","Percent of Total Billed Charges","neg_dollar:$250.40;Percent of Total Billed Charges","287.96","92","","","Percent of Total Billed Charges","neg_dollar:$287.96","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.00","313.00",""
"EXT ECG 7 TO 15 DAY SCAN W/ REPORT","93247","CPT","90001257","CDM","730","RC","","Facility","Outpatient","","","737","589.60","737.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","383.24","52","","","Percent of Total Billed Charges","neg_dollar:$383.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","737.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","383.24","52","","","Percent of Total Billed Charges","neg_dollar:$383.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","383.24","52","","","Percent of Total Billed Charges","neg_dollar:$383.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","383.24","52","","","Percent of Total Billed Charges","neg_dollar:$383.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","633.81","86","","","Percent of Total Billed Charges","neg_dollar:$633.81","515.90","70","","","Percent of Total Billed Charges","neg_dollar:$515.90","383.24","52","","","Percent of Total Billed Charges","neg_dollar:$383.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","432.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$432.98;102% of Medicaid interim rate","552.75","75","","","Percent of Total Billed Charges","neg_dollar:$552.75","633.81","86","","","Percent of Total Billed Charges","neg_dollar:$633.81","515.90","70","","","Percent of Total Billed Charges","neg_dollar:$515.90","420.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$420.09;103.5% of Medicaid interim rate","737.00","150","","","Percent of Total Billed Charges","neg_dollar:$1139.43;150% of Medicaid interim rate","589.60","80","","","Percent of Total Billed Charges","neg_dollar:$589.60;Percent of Total Billed Charges","678.04","92","","","Percent of Total Billed Charges","neg_dollar:$678.04","383.24","52","","","Percent of Total Billed Charges","neg_dollar:$383.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","383.24","52","","","Percent of Total Billed Charges","neg_dollar:$383.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","383.00","737.00",""
"REMOTE PT 30 DAY ECG REV/REPORT","93270","CPT","90000297","CDM","731","RC","","Facility","Outpatient","","","390","312.00","390.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","335.40","86","","","Percent of Total Billed Charges","neg_dollar:$335.40","273.00","70","","","Percent of Total Billed Charges","neg_dollar:$273","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","229.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$229.12;102% of Medicaid interim rate","292.50","75","","","Percent of Total Billed Charges","neg_dollar:$292.50","335.40","86","","","Percent of Total Billed Charges","neg_dollar:$335.40","273.00","70","","","Percent of Total Billed Charges","neg_dollar:$273","222.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$222.29;103.5% of Medicaid interim rate","390.00","150","","","Percent of Total Billed Charges","neg_dollar:$602.95;150% of Medicaid interim rate","312.00","80","","","Percent of Total Billed Charges","neg_dollar:$312;Percent of Total Billed Charges","358.80","92","","","Percent of Total Billed Charges","neg_dollar:$358.80","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","202.80","52","","","Percent of Total Billed Charges","neg_dollar:$202.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","202.00","390.00",""
"ECG/MONITOR AND ANALYSIS UP TO 30 DAYS","93271","CPT","90000298","CDM","731","RC","","Facility","Outpatient","","","706","564.80","706.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","367.12","52","","","Percent of Total Billed Charges","neg_dollar:$367.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","706.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","367.12","52","","","Percent of Total Billed Charges","neg_dollar:$367.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","367.12","52","","","Percent of Total Billed Charges","neg_dollar:$367.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","367.12","52","","","Percent of Total Billed Charges","neg_dollar:$367.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","607.16","86","","","Percent of Total Billed Charges","neg_dollar:$607.16","494.20","70","","","Percent of Total Billed Charges","neg_dollar:$494.20","367.12","52","","","Percent of Total Billed Charges","neg_dollar:$367.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","414.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$414.77;102% of Medicaid interim rate","529.50","75","","","Percent of Total Billed Charges","neg_dollar:$529.50","607.16","86","","","Percent of Total Billed Charges","neg_dollar:$607.16","494.20","70","","","Percent of Total Billed Charges","neg_dollar:$494.20","402.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$402.41;103.5% of Medicaid interim rate","706.00","150","","","Percent of Total Billed Charges","neg_dollar:$1091.51;150% of Medicaid interim rate","564.80","80","","","Percent of Total Billed Charges","neg_dollar:$564.80;Percent of Total Billed Charges","649.52","92","","","Percent of Total Billed Charges","neg_dollar:$649.52","367.12","52","","","Percent of Total Billed Charges","neg_dollar:$367.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","367.12","52","","","Percent of Total Billed Charges","neg_dollar:$367.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","367.00","706.00",""
"TTE W/ DOPPLER COMPLETE","93306","CPT","90000302","CDM","483","RC","","Facility","Outpatient","","","3976","3180.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2067.52","52","","","Percent of Total Billed Charges","neg_dollar:$2067.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2067.52","52","","","Percent of Total Billed Charges","neg_dollar:$2067.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","2067.52","52","","","Percent of Total Billed Charges","neg_dollar:$2067.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","2067.52","52","","","Percent of Total Billed Charges","neg_dollar:$2067.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","3419.36","86","","","Percent of Total Billed Charges","neg_dollar:$3419.36","2783.20","70","","","Percent of Total Billed Charges","neg_dollar:$2783.20","2067.52","52","","","Percent of Total Billed Charges","neg_dollar:$2067.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","2335.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$2335.89;102% of Medicaid interim rate","2982.00","75","","","Percent of Total Billed Charges","neg_dollar:$2982","3419.36","86","","","Percent of Total Billed Charges","neg_dollar:$3419.36","2783.20","70","","","Percent of Total Billed Charges","neg_dollar:$2783.20","2266.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$2266.31;103.5% of Medicaid interim rate","3976.00","150","","","Percent of Total Billed Charges","neg_dollar:$6147.09;150% of Medicaid interim rate","3180.80","80","","","Percent of Total Billed Charges","neg_dollar:$3180.80;Percent of Total Billed Charges","3657.92","92","","","Percent of Total Billed Charges","neg_dollar:$3657.92","2067.52","52","","","Percent of Total Billed Charges","neg_dollar:$2067.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","2067.52","52","","","Percent of Total Billed Charges","neg_dollar:$2067.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3976.00",""
"2-D ECHO LIMITED OR FOLLOWUP","93308","CPT","90000033","CDM","480","RC","","Facility","Outpatient","","","903","722.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","469.56","52","","","Percent of Total Billed Charges","neg_dollar:$469.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","469.56","52","","","Percent of Total Billed Charges","neg_dollar:$469.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","469.56","52","","","Percent of Total Billed Charges","neg_dollar:$469.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","469.56","52","","","Percent of Total Billed Charges","neg_dollar:$469.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","776.58","86","","","Percent of Total Billed Charges","neg_dollar:$776.58","632.09","70","","","Percent of Total Billed Charges","neg_dollar:$632.09","469.56","52","","","Percent of Total Billed Charges","neg_dollar:$469.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","530.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$530.51;102% of Medicaid interim rate","677.25","75","","","Percent of Total Billed Charges","neg_dollar:$677.25","776.58","86","","","Percent of Total Billed Charges","neg_dollar:$776.58","632.09","70","","","Percent of Total Billed Charges","neg_dollar:$632.09","514.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$514.70;103.5% of Medicaid interim rate","903.00","150","","","Percent of Total Billed Charges","neg_dollar:$1396.08;150% of Medicaid interim rate","722.40","80","","","Percent of Total Billed Charges","neg_dollar:$722.40;Percent of Total Billed Charges","830.76","92","","","Percent of Total Billed Charges","neg_dollar:$830.76","469.56","52","","","Percent of Total Billed Charges","neg_dollar:$469.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","469.56","52","","","Percent of Total Billed Charges","neg_dollar:$469.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","469.00","903.00",""
"DOPPLER ECHO; LIMITED/ F-UP","93321","CPT","90000308","CDM","483","RC","","Facility","Outpatient","","","538","430.40","538.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","538.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","462.68","86","","","Percent of Total Billed Charges","neg_dollar:$462.68","376.59","70","","","Percent of Total Billed Charges","neg_dollar:$376.59","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","316.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$316.07;102% of Medicaid interim rate","403.50","75","","","Percent of Total Billed Charges","neg_dollar:$403.50","462.68","86","","","Percent of Total Billed Charges","neg_dollar:$462.68","376.59","70","","","Percent of Total Billed Charges","neg_dollar:$376.59","306.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$306.65;103.5% of Medicaid interim rate","538.00","150","","","Percent of Total Billed Charges","neg_dollar:$831.77;150% of Medicaid interim rate","430.40","80","","","Percent of Total Billed Charges","neg_dollar:$430.40;Percent of Total Billed Charges","494.96","92","","","Percent of Total Billed Charges","neg_dollar:$494.96","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.76","52","","","Percent of Total Billed Charges","neg_dollar:$279.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.00","538.00",""
"DOPPLER COLOR FLOW","93325","CPT","90000309","CDM","483","RC","","Facility","Outpatient","","","112","89.60","112.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","112.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","96.32","86","","","Percent of Total Billed Charges","neg_dollar:$96.32","78.39","70","","","Percent of Total Billed Charges","neg_dollar:$78.39","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","65.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$65.79;102% of Medicaid interim rate","84.00","75","","","Percent of Total Billed Charges","neg_dollar:$84","96.32","86","","","Percent of Total Billed Charges","neg_dollar:$96.32","78.39","70","","","Percent of Total Billed Charges","neg_dollar:$78.39","63.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$63.83;103.5% of Medicaid interim rate","112.00","150","","","Percent of Total Billed Charges","neg_dollar:$173.15;150% of Medicaid interim rate","89.60","80","","","Percent of Total Billed Charges","neg_dollar:$89.60;Percent of Total Billed Charges","103.04","92","","","Percent of Total Billed Charges","neg_dollar:$103.04","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.00","112.00",""
"PAD REHAB PER SESSION","93668","CPT","90001097","CDM","480","RC","","Facility","Outpatient","","","218","174.40","218.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","218.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","187.48","86","","","Percent of Total Billed Charges","neg_dollar:$187.48","152.60","70","","","Percent of Total Billed Charges","neg_dollar:$152.60","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","128.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$128.07;102% of Medicaid interim rate","163.50","75","","","Percent of Total Billed Charges","neg_dollar:$163.50","187.48","86","","","Percent of Total Billed Charges","neg_dollar:$187.48","152.60","70","","","Percent of Total Billed Charges","neg_dollar:$152.60","124.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$124.25;103.5% of Medicaid interim rate","218.00","150","","","Percent of Total Billed Charges","neg_dollar:$337.03;150% of Medicaid interim rate","174.40","80","","","Percent of Total Billed Charges","neg_dollar:$174.40;Percent of Total Billed Charges","200.56","92","","","Percent of Total Billed Charges","neg_dollar:$200.56","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","113.00","218.00",""
"CARDIAC REHAB WO CONT ECG","93797","CPT","97000088","CDM","943","RC","","Facility","Outpatient","","","272","217.60","272.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","141.44","52","","","Percent of Total Billed Charges","neg_dollar:$141.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","272.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","141.44","52","","","Percent of Total Billed Charges","neg_dollar:$141.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","141.44","52","","","Percent of Total Billed Charges","neg_dollar:$141.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","141.44","52","","","Percent of Total Billed Charges","neg_dollar:$141.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","233.92","86","","","Percent of Total Billed Charges","neg_dollar:$233.92","190.39","70","","","Percent of Total Billed Charges","neg_dollar:$190.39","141.44","52","","","Percent of Total Billed Charges","neg_dollar:$141.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","159.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$159.79;102% of Medicaid interim rate","204.00","75","","","Percent of Total Billed Charges","neg_dollar:$204","233.92","86","","","Percent of Total Billed Charges","neg_dollar:$233.92","190.39","70","","","Percent of Total Billed Charges","neg_dollar:$190.39","155.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$155.04;103.5% of Medicaid interim rate","272.00","150","","","Percent of Total Billed Charges","neg_dollar:$420.52;150% of Medicaid interim rate","217.60","80","","","Percent of Total Billed Charges","neg_dollar:$217.60;Percent of Total Billed Charges","250.24","92","","","Percent of Total Billed Charges","neg_dollar:$250.24","141.44","52","","","Percent of Total Billed Charges","neg_dollar:$141.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","141.44","52","","","Percent of Total Billed Charges","neg_dollar:$141.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","141.00","272.00",""
"CARDIAC REHAB W CONT ECG PHASE II","93798","CPT","97000019","CDM","943","RC","","Facility","Outpatient","","","407","325.60","407.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","407.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","350.02","86","","","Percent of Total Billed Charges","neg_dollar:$350.02","284.90","70","","","Percent of Total Billed Charges","neg_dollar:$284.90","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","239.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$239.11;102% of Medicaid interim rate","305.25","75","","","Percent of Total Billed Charges","neg_dollar:$305.25","350.02","86","","","Percent of Total Billed Charges","neg_dollar:$350.02","284.90","70","","","Percent of Total Billed Charges","neg_dollar:$284.90","231.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$231.98;103.5% of Medicaid interim rate","407.00","150","","","Percent of Total Billed Charges","neg_dollar:$629.24;150% of Medicaid interim rate","325.60","80","","","Percent of Total Billed Charges","neg_dollar:$325.60;Percent of Total Billed Charges","374.44","92","","","Percent of Total Billed Charges","neg_dollar:$374.44","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","211.64","52","","","Percent of Total Billed Charges","neg_dollar:$211.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","211.00","407.00",""
"CAROTID DUPLEX SCAN; BILAT","93880","CPT","90000311","CDM","921","RC","","Facility","Outpatient","","","1043","834.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","542.36","52","","","Percent of Total Billed Charges","neg_dollar:$542.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","542.36","52","","","Percent of Total Billed Charges","neg_dollar:$542.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","542.36","52","","","Percent of Total Billed Charges","neg_dollar:$542.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","542.36","52","","","Percent of Total Billed Charges","neg_dollar:$542.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","896.98","86","","","Percent of Total Billed Charges","neg_dollar:$896.98","730.09","70","","","Percent of Total Billed Charges","neg_dollar:$730.09","542.36","52","","","Percent of Total Billed Charges","neg_dollar:$542.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","612.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$612.76;102% of Medicaid interim rate","782.25","75","","","Percent of Total Billed Charges","neg_dollar:$782.25","896.98","86","","","Percent of Total Billed Charges","neg_dollar:$896.98","730.09","70","","","Percent of Total Billed Charges","neg_dollar:$730.09","594.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$594.51;103.5% of Medicaid interim rate","1043.00","150","","","Percent of Total Billed Charges","neg_dollar:$1612.53;150% of Medicaid interim rate","834.40","80","","","Percent of Total Billed Charges","neg_dollar:$834.40;Percent of Total Billed Charges","959.56","92","","","Percent of Total Billed Charges","neg_dollar:$959.56","542.36","52","","","Percent of Total Billed Charges","neg_dollar:$542.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","542.36","52","","","Percent of Total Billed Charges","neg_dollar:$542.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","542.00","1043.00",""
"CAROTID DUPLEX SCAN; UNIL/LIMIT","93882","CPT","90000312","CDM","921","RC","","Facility","Outpatient","","","774","619.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","774.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","665.64","86","","","Percent of Total Billed Charges","neg_dollar:$665.64","541.80","70","","","Percent of Total Billed Charges","neg_dollar:$541.80","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","454.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$454.72;102% of Medicaid interim rate","580.50","75","","","Percent of Total Billed Charges","neg_dollar:$580.50","665.64","86","","","Percent of Total Billed Charges","neg_dollar:$665.64","541.80","70","","","Percent of Total Billed Charges","neg_dollar:$541.80","441.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$441.17;103.5% of Medicaid interim rate","774.00","150","","","Percent of Total Billed Charges","neg_dollar:$1196.64;150% of Medicaid interim rate","619.20","80","","","Percent of Total Billed Charges","neg_dollar:$619.20;Percent of Total Billed Charges","712.08","92","","","Percent of Total Billed Charges","neg_dollar:$712.08","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","402.00","774.00",""
"UPR/L XTREMITY ART 2 LEVELS","93922","CPT","90000066","CDM","921","RC","","Facility","Outpatient","","","191","152.80","191.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","99.32","52","","","Percent of Total Billed Charges","neg_dollar:$99.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","191.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","99.32","52","","","Percent of Total Billed Charges","neg_dollar:$99.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","99.32","52","","","Percent of Total Billed Charges","neg_dollar:$99.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","99.32","52","","","Percent of Total Billed Charges","neg_dollar:$99.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","164.26","86","","","Percent of Total Billed Charges","neg_dollar:$164.26","133.70","70","","","Percent of Total Billed Charges","neg_dollar:$133.70","99.32","52","","","Percent of Total Billed Charges","neg_dollar:$99.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","112.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$112.21;102% of Medicaid interim rate","143.25","75","","","Percent of Total Billed Charges","neg_dollar:$143.25","164.26","86","","","Percent of Total Billed Charges","neg_dollar:$164.26","133.70","70","","","Percent of Total Billed Charges","neg_dollar:$133.70","108.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$108.86;103.5% of Medicaid interim rate","191.00","150","","","Percent of Total Billed Charges","neg_dollar:$295.29;150% of Medicaid interim rate","152.80","80","","","Percent of Total Billed Charges","neg_dollar:$152.80;Percent of Total Billed Charges","175.72","92","","","Percent of Total Billed Charges","neg_dollar:$175.72","99.32","52","","","Percent of Total Billed Charges","neg_dollar:$99.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","99.32","52","","","Percent of Total Billed Charges","neg_dollar:$99.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","99.00","191.00",""
"DUPLEX LE ART/BPG; BILAT","93925","CPT","90000316","CDM","921","RC","","Facility","Outpatient","","","852","681.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","443.04","52","","","Percent of Total Billed Charges","neg_dollar:$443.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","443.04","52","","","Percent of Total Billed Charges","neg_dollar:$443.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","443.04","52","","","Percent of Total Billed Charges","neg_dollar:$443.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","443.04","52","","","Percent of Total Billed Charges","neg_dollar:$443.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","732.72","86","","","Percent of Total Billed Charges","neg_dollar:$732.72","596.40","70","","","Percent of Total Billed Charges","neg_dollar:$596.40","443.04","52","","","Percent of Total Billed Charges","neg_dollar:$443.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","500.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$500.54;102% of Medicaid interim rate","639.00","75","","","Percent of Total Billed Charges","neg_dollar:$639","732.72","86","","","Percent of Total Billed Charges","neg_dollar:$732.72","596.40","70","","","Percent of Total Billed Charges","neg_dollar:$596.40","485.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$485.64;103.5% of Medicaid interim rate","852.00","150","","","Percent of Total Billed Charges","neg_dollar:$1317.23;150% of Medicaid interim rate","681.60","80","","","Percent of Total Billed Charges","neg_dollar:$681.60;Percent of Total Billed Charges","783.84","92","","","Percent of Total Billed Charges","neg_dollar:$783.84","443.04","52","","","Percent of Total Billed Charges","neg_dollar:$443.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","443.04","52","","","Percent of Total Billed Charges","neg_dollar:$443.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","443.00","852.00",""
"DUPLEX LE ART/BPG; UNIL/LIMIT","93926","CPT","90000317","CDM","921","RC","","Facility","Outpatient","","","648","518.40","648.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","648.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","557.28","86","","","Percent of Total Billed Charges","neg_dollar:$557.28","453.59","70","","","Percent of Total Billed Charges","neg_dollar:$453.59","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","380.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$380.69;102% of Medicaid interim rate","486.00","75","","","Percent of Total Billed Charges","neg_dollar:$486","557.28","86","","","Percent of Total Billed Charges","neg_dollar:$557.28","453.59","70","","","Percent of Total Billed Charges","neg_dollar:$453.59","369.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$369.35;103.5% of Medicaid interim rate","648.00","150","","","Percent of Total Billed Charges","neg_dollar:$1001.84;150% of Medicaid interim rate","518.40","80","","","Percent of Total Billed Charges","neg_dollar:$518.40;Percent of Total Billed Charges","596.16","92","","","Percent of Total Billed Charges","neg_dollar:$596.16","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","336.96","52","","","Percent of Total Billed Charges","neg_dollar:$336.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","336.00","648.00",""
"DUPLEX UE ART/BPG; BILAT","93930","CPT","90000318","CDM","921","RC","","Facility","Outpatient","","","837","669.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","435.24","52","","","Percent of Total Billed Charges","neg_dollar:$435.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","435.24","52","","","Percent of Total Billed Charges","neg_dollar:$435.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","435.24","52","","","Percent of Total Billed Charges","neg_dollar:$435.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","435.24","52","","","Percent of Total Billed Charges","neg_dollar:$435.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","719.81","86","","","Percent of Total Billed Charges","neg_dollar:$719.81","585.90","70","","","Percent of Total Billed Charges","neg_dollar:$585.90","435.24","52","","","Percent of Total Billed Charges","neg_dollar:$435.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","491.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$491.73;102% of Medicaid interim rate","627.75","75","","","Percent of Total Billed Charges","neg_dollar:$627.75","719.81","86","","","Percent of Total Billed Charges","neg_dollar:$719.81","585.90","70","","","Percent of Total Billed Charges","neg_dollar:$585.90","477.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$477.09;103.5% of Medicaid interim rate","837.00","150","","","Percent of Total Billed Charges","neg_dollar:$1294.04;150% of Medicaid interim rate","669.60","80","","","Percent of Total Billed Charges","neg_dollar:$669.60;Percent of Total Billed Charges","770.04","92","","","Percent of Total Billed Charges","neg_dollar:$770.04","435.24","52","","","Percent of Total Billed Charges","neg_dollar:$435.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","435.24","52","","","Percent of Total Billed Charges","neg_dollar:$435.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","435.00","837.00",""
"DUPLEX UE ART/BPG; UNIL/LIMIT","93931","CPT","90000319","CDM","921","RC","","Facility","Outpatient","","","585","468.00","585.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","304.20","52","","","Percent of Total Billed Charges","neg_dollar:$304.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","585.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","304.20","52","","","Percent of Total Billed Charges","neg_dollar:$304.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","304.20","52","","","Percent of Total Billed Charges","neg_dollar:$304.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","304.20","52","","","Percent of Total Billed Charges","neg_dollar:$304.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","503.09","86","","","Percent of Total Billed Charges","neg_dollar:$503.09","409.50","70","","","Percent of Total Billed Charges","neg_dollar:$409.50","304.20","52","","","Percent of Total Billed Charges","neg_dollar:$304.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","343.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$343.68;102% of Medicaid interim rate","438.75","75","","","Percent of Total Billed Charges","neg_dollar:$438.75","503.09","86","","","Percent of Total Billed Charges","neg_dollar:$503.09","409.50","70","","","Percent of Total Billed Charges","neg_dollar:$409.50","333.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$333.45;103.5% of Medicaid interim rate","585.00","150","","","Percent of Total Billed Charges","neg_dollar:$904.43;150% of Medicaid interim rate","468.00","80","","","Percent of Total Billed Charges","neg_dollar:$468;Percent of Total Billed Charges","538.20","92","","","Percent of Total Billed Charges","neg_dollar:$538.20","304.20","52","","","Percent of Total Billed Charges","neg_dollar:$304.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","304.20","52","","","Percent of Total Billed Charges","neg_dollar:$304.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","304.00","585.00",""
"DUPLEX EXT VEINS; BILAT","93970","CPT","90000320","CDM","921","RC","","Facility","Outpatient","","","1520","1216.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","790.40","52","","","Percent of Total Billed Charges","neg_dollar:$790.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","790.40","52","","","Percent of Total Billed Charges","neg_dollar:$790.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","790.40","52","","","Percent of Total Billed Charges","neg_dollar:$790.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","790.40","52","","","Percent of Total Billed Charges","neg_dollar:$790.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1307.20","86","","","Percent of Total Billed Charges","neg_dollar:$1307.20","1064.00","70","","","Percent of Total Billed Charges","neg_dollar:$1064","790.40","52","","","Percent of Total Billed Charges","neg_dollar:$790.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","892.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$892.99;102% of Medicaid interim rate","1140.00","75","","","Percent of Total Billed Charges","neg_dollar:$1140","1307.20","86","","","Percent of Total Billed Charges","neg_dollar:$1307.20","1064.00","70","","","Percent of Total Billed Charges","neg_dollar:$1064","866.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$866.40;103.5% of Medicaid interim rate","1520.00","150","","","Percent of Total Billed Charges","neg_dollar:$2349.99;150% of Medicaid interim rate","1216.00","80","","","Percent of Total Billed Charges","neg_dollar:$1216;Percent of Total Billed Charges","1398.40","92","","","Percent of Total Billed Charges","neg_dollar:$1398.40","790.40","52","","","Percent of Total Billed Charges","neg_dollar:$790.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","790.40","52","","","Percent of Total Billed Charges","neg_dollar:$790.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1520.00",""
"DUPLEX EXT VEINS UNIL/LIMIT","93971","CPT","90000068","CDM","921","RC","","Facility","Outpatient","","","945","756.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","491.40","52","","","Percent of Total Billed Charges","neg_dollar:$491.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","491.40","52","","","Percent of Total Billed Charges","neg_dollar:$491.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","491.40","52","","","Percent of Total Billed Charges","neg_dollar:$491.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","491.40","52","","","Percent of Total Billed Charges","neg_dollar:$491.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","812.69","86","","","Percent of Total Billed Charges","neg_dollar:$812.69","661.50","70","","","Percent of Total Billed Charges","neg_dollar:$661.50","491.40","52","","","Percent of Total Billed Charges","neg_dollar:$491.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","555.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$555.18;102% of Medicaid interim rate","708.75","75","","","Percent of Total Billed Charges","neg_dollar:$708.75","812.69","86","","","Percent of Total Billed Charges","neg_dollar:$812.69","661.50","70","","","Percent of Total Billed Charges","neg_dollar:$661.50","538.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$538.65;103.5% of Medicaid interim rate","945.00","150","","","Percent of Total Billed Charges","neg_dollar:$1461.01;150% of Medicaid interim rate","756.00","80","","","Percent of Total Billed Charges","neg_dollar:$756;Percent of Total Billed Charges","869.40","92","","","Percent of Total Billed Charges","neg_dollar:$869.40","491.40","52","","","Percent of Total Billed Charges","neg_dollar:$491.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","491.40","52","","","Percent of Total Billed Charges","neg_dollar:$491.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","491.00","945.00",""
"US DUPLEX ARTERIAL FLOW COMPL","93975","CPT","90000162","CDM","921","RC","","Facility","Outpatient","","","774","619.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","774.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","665.64","86","","","Percent of Total Billed Charges","neg_dollar:$665.64","541.80","70","","","Percent of Total Billed Charges","neg_dollar:$541.80","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","454.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$454.72;102% of Medicaid interim rate","580.50","75","","","Percent of Total Billed Charges","neg_dollar:$580.50","665.64","86","","","Percent of Total Billed Charges","neg_dollar:$665.64","541.80","70","","","Percent of Total Billed Charges","neg_dollar:$541.80","441.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$441.17;103.5% of Medicaid interim rate","774.00","150","","","Percent of Total Billed Charges","neg_dollar:$1196.64;150% of Medicaid interim rate","619.20","80","","","Percent of Total Billed Charges","neg_dollar:$619.20;Percent of Total Billed Charges","712.08","92","","","Percent of Total Billed Charges","neg_dollar:$712.08","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","402.48","52","","","Percent of Total Billed Charges","neg_dollar:$402.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","402.00","774.00",""
"DUPLEX A IVC IL/BPG; COMPL","93978","CPT","90000321","CDM","921","RC","","Facility","Outpatient","","","1158","926.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","602.16","52","","","Percent of Total Billed Charges","neg_dollar:$602.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","602.16","52","","","Percent of Total Billed Charges","neg_dollar:$602.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","602.16","52","","","Percent of Total Billed Charges","neg_dollar:$602.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","602.16","52","","","Percent of Total Billed Charges","neg_dollar:$602.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","995.88","86","","","Percent of Total Billed Charges","neg_dollar:$995.88","810.59","70","","","Percent of Total Billed Charges","neg_dollar:$810.59","602.16","52","","","Percent of Total Billed Charges","neg_dollar:$602.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","680.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$680.32;102% of Medicaid interim rate","868.50","75","","","Percent of Total Billed Charges","neg_dollar:$868.50","995.88","86","","","Percent of Total Billed Charges","neg_dollar:$995.88","810.59","70","","","Percent of Total Billed Charges","neg_dollar:$810.59","660.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$660.06;103.5% of Medicaid interim rate","1158.00","150","","","Percent of Total Billed Charges","neg_dollar:$1790.32;150% of Medicaid interim rate","926.40","80","","","Percent of Total Billed Charges","neg_dollar:$926.40;Percent of Total Billed Charges","1065.36","92","","","Percent of Total Billed Charges","neg_dollar:$1065.36","602.16","52","","","Percent of Total Billed Charges","neg_dollar:$602.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","602.16","52","","","Percent of Total Billed Charges","neg_dollar:$602.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","602.00","1158.00",""
"DUPLEX A IVC IL/BPG; UNIL/LIMIT","93979","CPT","90000322","CDM","921","RC","","Facility","Outpatient","","","985","788.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","512.20","52","","","Percent of Total Billed Charges","neg_dollar:$512.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","512.20","52","","","Percent of Total Billed Charges","neg_dollar:$512.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","512.20","52","","","Percent of Total Billed Charges","neg_dollar:$512.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","512.20","52","","","Percent of Total Billed Charges","neg_dollar:$512.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","847.10","86","","","Percent of Total Billed Charges","neg_dollar:$847.10","689.50","70","","","Percent of Total Billed Charges","neg_dollar:$689.50","512.20","52","","","Percent of Total Billed Charges","neg_dollar:$512.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","578.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$578.68;102% of Medicaid interim rate","738.75","75","","","Percent of Total Billed Charges","neg_dollar:$738.75","847.10","86","","","Percent of Total Billed Charges","neg_dollar:$847.10","689.50","70","","","Percent of Total Billed Charges","neg_dollar:$689.50","561.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$561.44;103.5% of Medicaid interim rate","985.00","150","","","Percent of Total Billed Charges","neg_dollar:$1522.85;150% of Medicaid interim rate","788.00","80","","","Percent of Total Billed Charges","neg_dollar:$788;Percent of Total Billed Charges","906.20","92","","","Percent of Total Billed Charges","neg_dollar:$906.20","512.20","52","","","Percent of Total Billed Charges","neg_dollar:$512.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","512.20","52","","","Percent of Total Billed Charges","neg_dollar:$512.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","512.00","985.00",""
"VENT MGMT INPAT INIT DAY","94002","CPT","90000070","CDM","410","RC","","Facility","Outpatient","","","1533","1226.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","797.16","52","","","Percent of Total Billed Charges","neg_dollar:$797.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","797.16","52","","","Percent of Total Billed Charges","neg_dollar:$797.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","797.16","52","","","Percent of Total Billed Charges","neg_dollar:$797.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","797.16","52","","","Percent of Total Billed Charges","neg_dollar:$797.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1318.37","86","","","Percent of Total Billed Charges","neg_dollar:$1318.37","1073.10","70","","","Percent of Total Billed Charges","neg_dollar:$1073.10","797.16","52","","","Percent of Total Billed Charges","neg_dollar:$797.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","900.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$900.63;102% of Medicaid interim rate","1149.75","75","","","Percent of Total Billed Charges","neg_dollar:$1149.75","1318.37","86","","","Percent of Total Billed Charges","neg_dollar:$1318.37","1073.10","70","","","Percent of Total Billed Charges","neg_dollar:$1073.10","873.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$873.81;103.5% of Medicaid interim rate","1533.00","150","","","Percent of Total Billed Charges","neg_dollar:$2370.09;150% of Medicaid interim rate","1226.40","80","","","Percent of Total Billed Charges","neg_dollar:$1226.40;Percent of Total Billed Charges","1410.36","92","","","Percent of Total Billed Charges","neg_dollar:$1410.36","797.16","52","","","Percent of Total Billed Charges","neg_dollar:$797.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","797.16","52","","","Percent of Total Billed Charges","neg_dollar:$797.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1533.00",""
"VENT MGMT INPAT SUBQ DAY","94003","CPT","90000071","CDM","410","RC","","Facility","Outpatient","","","1436","1148.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","746.72","52","","","Percent of Total Billed Charges","neg_dollar:$746.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","746.72","52","","","Percent of Total Billed Charges","neg_dollar:$746.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","746.72","52","","","Percent of Total Billed Charges","neg_dollar:$746.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","746.72","52","","","Percent of Total Billed Charges","neg_dollar:$746.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1234.96","86","","","Percent of Total Billed Charges","neg_dollar:$1234.96","1005.19","70","","","Percent of Total Billed Charges","neg_dollar:$1005.19","746.72","52","","","Percent of Total Billed Charges","neg_dollar:$746.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","843.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$843.64;102% of Medicaid interim rate","1077.00","75","","","Percent of Total Billed Charges","neg_dollar:$1077","1234.96","86","","","Percent of Total Billed Charges","neg_dollar:$1234.96","1005.19","70","","","Percent of Total Billed Charges","neg_dollar:$1005.19","818.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$818.52;103.5% of Medicaid interim rate","1436.00","150","","","Percent of Total Billed Charges","neg_dollar:$2220.12;150% of Medicaid interim rate","1148.80","80","","","Percent of Total Billed Charges","neg_dollar:$1148.80;Percent of Total Billed Charges","1321.12","92","","","Percent of Total Billed Charges","neg_dollar:$1321.12","746.72","52","","","Percent of Total Billed Charges","neg_dollar:$746.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","746.72","52","","","Percent of Total Billed Charges","neg_dollar:$746.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","746.00","1436.00",""
"SPIROMETRY","94010","CPT","90000072","CDM","460","RC","","Facility","Outpatient","","","275","220.00","275.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","143.00","52","","","Percent of Total Billed Charges","neg_dollar:$143;101% Medicare Outpatient Cost to Charge Ratio of 52%","275.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","143.00","52","","","Percent of Total Billed Charges","neg_dollar:$143;102% Medicare Outpatient Cost to Charge Ratio of 52%","143.00","52","","","Percent of Total Billed Charges","neg_dollar:$143;102% Medicare Outpatient Cost to Charge Ratio of 52%","143.00","52","","","Percent of Total Billed Charges","neg_dollar:$143;102% Medicare Outpatient Cost to Charge Ratio of 52%","236.50","86","","","Percent of Total Billed Charges","neg_dollar:$236.50","192.50","70","","","Percent of Total Billed Charges","neg_dollar:$192.50","143.00","52","","","Percent of Total Billed Charges","neg_dollar:$143;105% Medicare Outpatient Cost to Charge Ratio of 52%","161.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$161.56;102% of Medicaid interim rate","206.25","75","","","Percent of Total Billed Charges","neg_dollar:$206.25","236.50","86","","","Percent of Total Billed Charges","neg_dollar:$236.50","192.50","70","","","Percent of Total Billed Charges","neg_dollar:$192.50","156.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$156.75;103.5% of Medicaid interim rate","275.00","150","","","Percent of Total Billed Charges","neg_dollar:$425.16;150% of Medicaid interim rate","220.00","80","","","Percent of Total Billed Charges","neg_dollar:$220;Percent of Total Billed Charges","253.00","92","","","Percent of Total Billed Charges","neg_dollar:$253","143.00","52","","","Percent of Total Billed Charges","neg_dollar:$143;100% Medicare Outpatient Cost to Charge Ratio of 52%","143.00","52","","","Percent of Total Billed Charges","neg_dollar:$143;100% Medicare Outpatient Cost to Charge Ratio of 52%","143.00","275.00",""
"BRONCHOSPASM PRE & POST BD","94060","CPT","90000073","CDM","460","RC","","Facility","Outpatient","","","564","451.20","564.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","564.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","331.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$331.34;102% of Medicaid interim rate","423.00","75","","","Percent of Total Billed Charges","neg_dollar:$423","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","321.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$321.47;103.5% of Medicaid interim rate","564.00","150","","","Percent of Total Billed Charges","neg_dollar:$871.97;150% of Medicaid interim rate","451.20","80","","","Percent of Total Billed Charges","neg_dollar:$451.20;Percent of Total Billed Charges","518.88","92","","","Percent of Total Billed Charges","neg_dollar:$518.88","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","293.00","564.00",""
"TOTAL VITAL CAPACITY","94150","CPT","90000074","CDM","460","RC","","Facility","Outpatient","","","180","144.00","180.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","180.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.80","86","","","Percent of Total Billed Charges","neg_dollar:$154.80","125.99","70","","","Percent of Total Billed Charges","neg_dollar:$125.99","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","105.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$105.74;102% of Medicaid interim rate","135.00","75","","","Percent of Total Billed Charges","neg_dollar:$135","154.80","86","","","Percent of Total Billed Charges","neg_dollar:$154.80","125.99","70","","","Percent of Total Billed Charges","neg_dollar:$125.99","102.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$102.60;103.5% of Medicaid interim rate","180.00","150","","","Percent of Total Billed Charges","neg_dollar:$278.28;150% of Medicaid interim rate","144.00","80","","","Percent of Total Billed Charges","neg_dollar:$144;Percent of Total Billed Charges","165.60","92","","","Percent of Total Billed Charges","neg_dollar:$165.60","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","93.60","52","","","Percent of Total Billed Charges","neg_dollar:$93.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","93.00","180.00",""
"MAXIMAL VOLUNTARY VENTILATION","94200","CPT","90000167","CDM","460","RC","","Facility","Outpatient","","","218","174.40","218.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","218.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","187.48","86","","","Percent of Total Billed Charges","neg_dollar:$187.48","152.60","70","","","Percent of Total Billed Charges","neg_dollar:$152.60","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","128.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$128.07;102% of Medicaid interim rate","163.50","75","","","Percent of Total Billed Charges","neg_dollar:$163.50","187.48","86","","","Percent of Total Billed Charges","neg_dollar:$187.48","152.60","70","","","Percent of Total Billed Charges","neg_dollar:$152.60","124.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$124.25;103.5% of Medicaid interim rate","218.00","150","","","Percent of Total Billed Charges","neg_dollar:$337.03;150% of Medicaid interim rate","174.40","80","","","Percent of Total Billed Charges","neg_dollar:$174.40;Percent of Total Billed Charges","200.56","92","","","Percent of Total Billed Charges","neg_dollar:$200.56","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","113.00","218.00",""
"FLOW VOLUME LOOP","94375","CPT","90000324","CDM","460","RC","","Facility","Outpatient","","","327","261.60","327.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","170.04","52","","","Percent of Total Billed Charges","neg_dollar:$170.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","327.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","170.04","52","","","Percent of Total Billed Charges","neg_dollar:$170.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","170.04","52","","","Percent of Total Billed Charges","neg_dollar:$170.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","170.04","52","","","Percent of Total Billed Charges","neg_dollar:$170.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","281.21","86","","","Percent of Total Billed Charges","neg_dollar:$281.21","228.89","70","","","Percent of Total Billed Charges","neg_dollar:$228.89","170.04","52","","","Percent of Total Billed Charges","neg_dollar:$170.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","192.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$192.11;102% of Medicaid interim rate","245.25","75","","","Percent of Total Billed Charges","neg_dollar:$245.25","281.21","86","","","Percent of Total Billed Charges","neg_dollar:$281.21","228.89","70","","","Percent of Total Billed Charges","neg_dollar:$228.89","186.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$186.39;103.5% of Medicaid interim rate","327.00","150","","","Percent of Total Billed Charges","neg_dollar:$505.55;150% of Medicaid interim rate","261.60","80","","","Percent of Total Billed Charges","neg_dollar:$261.60;Percent of Total Billed Charges","300.84","92","","","Percent of Total Billed Charges","neg_dollar:$300.84","170.04","52","","","Percent of Total Billed Charges","neg_dollar:$170.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","170.04","52","","","Percent of Total Billed Charges","neg_dollar:$170.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","170.00","327.00",""
"EXERCISE TST BRNCSPSM W ECG","94617","CPT","90001107","CDM","460","RC","","Facility","Outpatient","","","564","451.20","564.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","564.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","331.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$331.34;102% of Medicaid interim rate","423.00","75","","","Percent of Total Billed Charges","neg_dollar:$423","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","321.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$321.47;103.5% of Medicaid interim rate","564.00","150","","","Percent of Total Billed Charges","neg_dollar:$871.97;150% of Medicaid interim rate","451.20","80","","","Percent of Total Billed Charges","neg_dollar:$451.20;Percent of Total Billed Charges","518.88","92","","","Percent of Total Billed Charges","neg_dollar:$518.88","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","293.28","52","","","Percent of Total Billed Charges","neg_dollar:$293.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","293.00","564.00",""
"PULMONARY STRESS TESTING","94618","CPT","90001108","CDM","460","RC","","Facility","Outpatient","","","270","216.00","270.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","270.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","232.20","86","","","Percent of Total Billed Charges","neg_dollar:$232.20","189.00","70","","","Percent of Total Billed Charges","neg_dollar:$189","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","158.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$158.62;102% of Medicaid interim rate","202.50","75","","","Percent of Total Billed Charges","neg_dollar:$202.50","232.20","86","","","Percent of Total Billed Charges","neg_dollar:$232.20","189.00","70","","","Percent of Total Billed Charges","neg_dollar:$189","153.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$153.89;103.5% of Medicaid interim rate","270.00","150","","","Percent of Total Billed Charges","neg_dollar:$417.43;150% of Medicaid interim rate","216.00","80","","","Percent of Total Billed Charges","neg_dollar:$216;Percent of Total Billed Charges","248.40","92","","","Percent of Total Billed Charges","neg_dollar:$248.40","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","140.00","270.00",""
"PHY/QHP OP PULM RHB W/O MNTR PER SESSION","94625","CPT","90001353","CDM","948","RC","","Facility","Outpatient","","","284","227.20","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","284.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","166.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$166.84;102% of Medicaid interim rate","213.00","75","","","Percent of Total Billed Charges","neg_dollar:$213","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","161.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$161.88;103.5% of Medicaid interim rate","284.00","150","","","Percent of Total Billed Charges","neg_dollar:$439.07;150% of Medicaid interim rate","227.20","80","","","Percent of Total Billed Charges","neg_dollar:$227.20;Percent of Total Billed Charges","261.28","92","","","Percent of Total Billed Charges","neg_dollar:$261.28","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.68","52","","","Percent of Total Billed Charges","neg_dollar:$147.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","147.00","284.00",""
"PHY/QHP OP PULM RHB W/ MNTR PER SESSION","94626","CPT","90001354","CDM","948","RC","","Facility","Outpatient","","","324","259.20","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","324.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","190.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$190.34;102% of Medicaid interim rate","243.00","75","","","Percent of Total Billed Charges","neg_dollar:$243","278.64","86","","","Percent of Total Billed Charges","neg_dollar:$278.64","226.79","70","","","Percent of Total Billed Charges","neg_dollar:$226.79","184.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$184.67;103.5% of Medicaid interim rate","324.00","150","","","Percent of Total Billed Charges","neg_dollar:$500.92;150% of Medicaid interim rate","259.20","80","","","Percent of Total Billed Charges","neg_dollar:$259.20;Percent of Total Billed Charges","298.08","92","","","Percent of Total Billed Charges","neg_dollar:$298.08","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.48","52","","","Percent of Total Billed Charges","neg_dollar:$168.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","168.00","324.00",""
"AIRWAY INHALATION TREATMENT INITIAL","94640","CPT","90000102","CDM","410","RC","","Facility","Outpatient","","","263","210.40","263.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","263.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","226.18","86","","","Percent of Total Billed Charges","neg_dollar:$226.18","184.10","70","","","Percent of Total Billed Charges","neg_dollar:$184.10","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","154.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$154.51;102% of Medicaid interim rate","197.25","75","","","Percent of Total Billed Charges","neg_dollar:$197.25","226.18","86","","","Percent of Total Billed Charges","neg_dollar:$226.18","184.10","70","","","Percent of Total Billed Charges","neg_dollar:$184.10","149.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$149.91;103.5% of Medicaid interim rate","263.00","150","","","Percent of Total Billed Charges","neg_dollar:$406.61;150% of Medicaid interim rate","210.40","80","","","Percent of Total Billed Charges","neg_dollar:$210.40;Percent of Total Billed Charges","241.96","92","","","Percent of Total Billed Charges","neg_dollar:$241.96","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","136.00","263.00",""
"MDI AIRWAY INHALATION TX INITIAL","94640","CPT","90000103","CDM","410","RC","","Facility","Outpatient","","","263","210.40","263.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","263.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","226.18","86","","","Percent of Total Billed Charges","neg_dollar:$226.18","184.10","70","","","Percent of Total Billed Charges","neg_dollar:$184.10","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","154.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$154.51;102% of Medicaid interim rate","197.25","75","","","Percent of Total Billed Charges","neg_dollar:$197.25","226.18","86","","","Percent of Total Billed Charges","neg_dollar:$226.18","184.10","70","","","Percent of Total Billed Charges","neg_dollar:$184.10","149.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$149.91;103.5% of Medicaid interim rate","263.00","150","","","Percent of Total Billed Charges","neg_dollar:$406.61;150% of Medicaid interim rate","210.40","80","","","Percent of Total Billed Charges","neg_dollar:$210.40;Percent of Total Billed Charges","241.96","92","","","Percent of Total Billed Charges","neg_dollar:$241.96","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","136.76","52","","","Percent of Total Billed Charges","neg_dollar:$136.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","136.00","263.00",""
"AIRWAY INHALATION TREATMENT SUBQ","94640","CPT","90000104","CDM","410","RC","","Facility","Outpatient","","","250","200.00","250.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;101% Medicare Outpatient Cost to Charge Ratio of 52%","250.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;105% Medicare Outpatient Cost to Charge Ratio of 52%","146.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$146.87;102% of Medicaid interim rate","187.50","75","","","Percent of Total Billed Charges","neg_dollar:$187.50","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","142.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$142.50;103.5% of Medicaid interim rate","250.00","150","","","Percent of Total Billed Charges","neg_dollar:$386.51;150% of Medicaid interim rate","200.00","80","","","Percent of Total Billed Charges","neg_dollar:$200;Percent of Total Billed Charges","230.00","92","","","Percent of Total Billed Charges","neg_dollar:$230","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;100% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;100% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","250.00",""
"MDI AIRWAY INHALATION TX SUBQ","94640","CPT","90000105","CDM","410","RC","","Facility","Outpatient","","","250","200.00","250.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;101% Medicare Outpatient Cost to Charge Ratio of 52%","250.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;105% Medicare Outpatient Cost to Charge Ratio of 52%","146.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$146.87;102% of Medicaid interim rate","187.50","75","","","Percent of Total Billed Charges","neg_dollar:$187.50","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","142.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$142.50;103.5% of Medicaid interim rate","250.00","150","","","Percent of Total Billed Charges","neg_dollar:$386.51;150% of Medicaid interim rate","200.00","80","","","Percent of Total Billed Charges","neg_dollar:$200;Percent of Total Billed Charges","230.00","92","","","Percent of Total Billed Charges","neg_dollar:$230","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;100% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;100% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","250.00",""
"AEROSOL PENTAMIDEN FOR P CARINII","94642","CPT","90000190","CDM","410","RC","","Facility","Outpatient","","","453","362.40","453.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","453.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","389.58","86","","","Percent of Total Billed Charges","neg_dollar:$389.58","317.09","70","","","Percent of Total Billed Charges","neg_dollar:$317.09","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","266.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$266.13;102% of Medicaid interim rate","339.75","75","","","Percent of Total Billed Charges","neg_dollar:$339.75","389.58","86","","","Percent of Total Billed Charges","neg_dollar:$389.58","317.09","70","","","Percent of Total Billed Charges","neg_dollar:$317.09","258.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$258.21;103.5% of Medicaid interim rate","453.00","150","","","Percent of Total Billed Charges","neg_dollar:$700.36;150% of Medicaid interim rate","362.40","80","","","Percent of Total Billed Charges","neg_dollar:$362.40;Percent of Total Billed Charges","416.76","92","","","Percent of Total Billed Charges","neg_dollar:$416.76","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","235.00","453.00",""
"CONT BRONCHODILATOR TX 1ST HOUR","94644","CPT","90000078","CDM","410","RC","","Facility","Outpatient","","","238","190.40","238.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","123.76","52","","","Percent of Total Billed Charges","neg_dollar:$123.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","238.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","123.76","52","","","Percent of Total Billed Charges","neg_dollar:$123.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","123.76","52","","","Percent of Total Billed Charges","neg_dollar:$123.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","123.76","52","","","Percent of Total Billed Charges","neg_dollar:$123.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","204.68","86","","","Percent of Total Billed Charges","neg_dollar:$204.68","166.60","70","","","Percent of Total Billed Charges","neg_dollar:$166.60","123.76","52","","","Percent of Total Billed Charges","neg_dollar:$123.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","139.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$139.82;102% of Medicaid interim rate","178.50","75","","","Percent of Total Billed Charges","neg_dollar:$178.50","204.68","86","","","Percent of Total Billed Charges","neg_dollar:$204.68","166.60","70","","","Percent of Total Billed Charges","neg_dollar:$166.60","135.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$135.66;103.5% of Medicaid interim rate","238.00","150","","","Percent of Total Billed Charges","neg_dollar:$367.95;150% of Medicaid interim rate","190.40","80","","","Percent of Total Billed Charges","neg_dollar:$190.40;Percent of Total Billed Charges","218.96","92","","","Percent of Total Billed Charges","neg_dollar:$218.96","123.76","52","","","Percent of Total Billed Charges","neg_dollar:$123.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","123.76","52","","","Percent of Total Billed Charges","neg_dollar:$123.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","123.00","238.00",""
"CONT BRONCHODILATOR TX EA ADDL HOUR","94645","CPT","90000079","CDM","410","RC","","Facility","Outpatient","","","172","137.60","172.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","89.44","52","","","Percent of Total Billed Charges","neg_dollar:$89.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","172.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","89.44","52","","","Percent of Total Billed Charges","neg_dollar:$89.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","89.44","52","","","Percent of Total Billed Charges","neg_dollar:$89.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","89.44","52","","","Percent of Total Billed Charges","neg_dollar:$89.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","147.92","86","","","Percent of Total Billed Charges","neg_dollar:$147.92","120.39","70","","","Percent of Total Billed Charges","neg_dollar:$120.39","89.44","52","","","Percent of Total Billed Charges","neg_dollar:$89.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","101.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$101.04;102% of Medicaid interim rate","129.00","75","","","Percent of Total Billed Charges","neg_dollar:$129","147.92","86","","","Percent of Total Billed Charges","neg_dollar:$147.92","120.39","70","","","Percent of Total Billed Charges","neg_dollar:$120.39","98.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$98.03;103.5% of Medicaid interim rate","172.00","150","","","Percent of Total Billed Charges","neg_dollar:$265.92;150% of Medicaid interim rate","137.60","80","","","Percent of Total Billed Charges","neg_dollar:$137.60;Percent of Total Billed Charges","158.24","92","","","Percent of Total Billed Charges","neg_dollar:$158.24","89.44","52","","","Percent of Total Billed Charges","neg_dollar:$89.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","89.44","52","","","Percent of Total Billed Charges","neg_dollar:$89.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","89.00","172.00",""
"POS AIRWAY PRESSURE CPAP/BIPAP INITIAL","94660","CPT","90000652","CDM","410","RC","","Facility","Outpatient","","","1408","1126.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","1210.87","86","","","Percent of Total Billed Charges","neg_dollar:$1210.87","985.59","70","","","Percent of Total Billed Charges","neg_dollar:$985.59","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","827.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$827.19;102% of Medicaid interim rate","1056.00","75","","","Percent of Total Billed Charges","neg_dollar:$1056","1210.87","86","","","Percent of Total Billed Charges","neg_dollar:$1210.87","985.59","70","","","Percent of Total Billed Charges","neg_dollar:$985.59","802.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$802.56;103.5% of Medicaid interim rate","1408.00","150","","","Percent of Total Billed Charges","neg_dollar:$2176.83;150% of Medicaid interim rate","1126.40","80","","","Percent of Total Billed Charges","neg_dollar:$1126.40;Percent of Total Billed Charges","1295.36","92","","","Percent of Total Billed Charges","neg_dollar:$1295.36","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","732.16","52","","","Percent of Total Billed Charges","neg_dollar:$732.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","732.00","1408.00",""
"POS AIRWAY PRESSURE CPAP/BIPAP SUBQ","94660","CPT","90000653","CDM","410","RC","","Facility","Outpatient","","","1338","1070.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1150.68","86","","","Percent of Total Billed Charges","neg_dollar:$1150.68","936.59","70","","","Percent of Total Billed Charges","neg_dollar:$936.59","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","786.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$786.07;102% of Medicaid interim rate","1003.50","75","","","Percent of Total Billed Charges","neg_dollar:$1003.50","1150.68","86","","","Percent of Total Billed Charges","neg_dollar:$1150.68","936.59","70","","","Percent of Total Billed Charges","neg_dollar:$936.59","762.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$762.66;103.5% of Medicaid interim rate","1338.00","150","","","Percent of Total Billed Charges","neg_dollar:$2068.61;150% of Medicaid interim rate","1070.40","80","","","Percent of Total Billed Charges","neg_dollar:$1070.40;Percent of Total Billed Charges","1230.96","92","","","Percent of Total Billed Charges","neg_dollar:$1230.96","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","695.00","1338.00",""
"EVALUATE PT USE OF INHALER","94664","CPT","90000108","CDM","410","RC","","Facility","Outpatient","","","250","200.00","250.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;101% Medicare Outpatient Cost to Charge Ratio of 52%","250.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;105% Medicare Outpatient Cost to Charge Ratio of 52%","146.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$146.87;102% of Medicaid interim rate","187.50","75","","","Percent of Total Billed Charges","neg_dollar:$187.50","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","142.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$142.50;103.5% of Medicaid interim rate","250.00","150","","","Percent of Total Billed Charges","neg_dollar:$386.51;150% of Medicaid interim rate","200.00","80","","","Percent of Total Billed Charges","neg_dollar:$200;Percent of Total Billed Charges","230.00","92","","","Percent of Total Billed Charges","neg_dollar:$230","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;100% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;100% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","250.00",""
"CHEST PT INIT OR EVAL","94667","CPT","90000109","CDM","410","RC","","Facility","Outpatient","","","218","174.40","218.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","218.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","187.48","86","","","Percent of Total Billed Charges","neg_dollar:$187.48","152.60","70","","","Percent of Total Billed Charges","neg_dollar:$152.60","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","128.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$128.07;102% of Medicaid interim rate","163.50","75","","","Percent of Total Billed Charges","neg_dollar:$163.50","187.48","86","","","Percent of Total Billed Charges","neg_dollar:$187.48","152.60","70","","","Percent of Total Billed Charges","neg_dollar:$152.60","124.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$124.25;103.5% of Medicaid interim rate","218.00","150","","","Percent of Total Billed Charges","neg_dollar:$337.03;150% of Medicaid interim rate","174.40","80","","","Percent of Total Billed Charges","neg_dollar:$174.40;Percent of Total Billed Charges","200.56","92","","","Percent of Total Billed Charges","neg_dollar:$200.56","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","113.00","218.00",""
"FLUTTER VALVE/ACAPELLA CHEST PT INIT","94667","CPT","90000110","CDM","410","RC","","Facility","Outpatient","","","218","174.40","218.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","218.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","187.48","86","","","Percent of Total Billed Charges","neg_dollar:$187.48","152.60","70","","","Percent of Total Billed Charges","neg_dollar:$152.60","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","128.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$128.07;102% of Medicaid interim rate","163.50","75","","","Percent of Total Billed Charges","neg_dollar:$163.50","187.48","86","","","Percent of Total Billed Charges","neg_dollar:$187.48","152.60","70","","","Percent of Total Billed Charges","neg_dollar:$152.60","124.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$124.25;103.5% of Medicaid interim rate","218.00","150","","","Percent of Total Billed Charges","neg_dollar:$337.03;150% of Medicaid interim rate","174.40","80","","","Percent of Total Billed Charges","neg_dollar:$174.40;Percent of Total Billed Charges","200.56","92","","","Percent of Total Billed Charges","neg_dollar:$200.56","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","113.36","52","","","Percent of Total Billed Charges","neg_dollar:$113.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","113.00","218.00",""
"CHEST PT SUBSEQUENT","94668","CPT","90000111","CDM","410","RC","","Facility","Outpatient","","","161","128.80","161.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","161.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","138.46","86","","","Percent of Total Billed Charges","neg_dollar:$138.46","112.69","70","","","Percent of Total Billed Charges","neg_dollar:$112.69","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","94.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$94.58;102% of Medicaid interim rate","120.75","75","","","Percent of Total Billed Charges","neg_dollar:$120.75","138.46","86","","","Percent of Total Billed Charges","neg_dollar:$138.46","112.69","70","","","Percent of Total Billed Charges","neg_dollar:$112.69","91.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$91.77;103.5% of Medicaid interim rate","161.00","150","","","Percent of Total Billed Charges","neg_dollar:$248.91;150% of Medicaid interim rate","128.80","80","","","Percent of Total Billed Charges","neg_dollar:$128.80;Percent of Total Billed Charges","148.12","92","","","Percent of Total Billed Charges","neg_dollar:$148.12","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","83.00","161.00",""
"FLUTTER VALVE/ACAPELLA CHEST PT SUBQ","94668","CPT","90000112","CDM","410","RC","","Facility","Outpatient","","","161","128.80","161.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","161.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","138.46","86","","","Percent of Total Billed Charges","neg_dollar:$138.46","112.69","70","","","Percent of Total Billed Charges","neg_dollar:$112.69","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","94.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$94.58;102% of Medicaid interim rate","120.75","75","","","Percent of Total Billed Charges","neg_dollar:$120.75","138.46","86","","","Percent of Total Billed Charges","neg_dollar:$138.46","112.69","70","","","Percent of Total Billed Charges","neg_dollar:$112.69","91.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$91.77;103.5% of Medicaid interim rate","161.00","150","","","Percent of Total Billed Charges","neg_dollar:$248.91;150% of Medicaid interim rate","128.80","80","","","Percent of Total Billed Charges","neg_dollar:$128.80;Percent of Total Billed Charges","148.12","92","","","Percent of Total Billed Charges","neg_dollar:$148.12","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","83.72","52","","","Percent of Total Billed Charges","neg_dollar:$83.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","83.00","161.00",""
"PULM FUNCT TST PLETHYSMOGRAP","94726","CPT","90000455","CDM","460","RC","","Facility","Outpatient","","","440","352.00","440.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","440.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","378.40","86","","","Percent of Total Billed Charges","neg_dollar:$378.40","308.00","70","","","Percent of Total Billed Charges","neg_dollar:$308","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","258.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$258.49;102% of Medicaid interim rate","330.00","75","","","Percent of Total Billed Charges","neg_dollar:$330","378.40","86","","","Percent of Total Billed Charges","neg_dollar:$378.40","308.00","70","","","Percent of Total Billed Charges","neg_dollar:$308","250.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$250.79;103.5% of Medicaid interim rate","440.00","150","","","Percent of Total Billed Charges","neg_dollar:$680.26;150% of Medicaid interim rate","352.00","80","","","Percent of Total Billed Charges","neg_dollar:$352;Percent of Total Billed Charges","404.80","92","","","Percent of Total Billed Charges","neg_dollar:$404.80","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","228.80","52","","","Percent of Total Billed Charges","neg_dollar:$228.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","228.00","440.00",""
"C0/MEMBRANE DIFFUSE CAPACITY","94729","CPT","90000458","CDM","460","RC","","Facility","Outpatient","","","286","228.80","286.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","148.72","52","","","Percent of Total Billed Charges","neg_dollar:$148.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","286.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","148.72","52","","","Percent of Total Billed Charges","neg_dollar:$148.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","148.72","52","","","Percent of Total Billed Charges","neg_dollar:$148.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","148.72","52","","","Percent of Total Billed Charges","neg_dollar:$148.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","245.96","86","","","Percent of Total Billed Charges","neg_dollar:$245.96","200.20","70","","","Percent of Total Billed Charges","neg_dollar:$200.20","148.72","52","","","Percent of Total Billed Charges","neg_dollar:$148.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","168.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$168.02;102% of Medicaid interim rate","214.50","75","","","Percent of Total Billed Charges","neg_dollar:$214.50","245.96","86","","","Percent of Total Billed Charges","neg_dollar:$245.96","200.20","70","","","Percent of Total Billed Charges","neg_dollar:$200.20","163.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$163.01;103.5% of Medicaid interim rate","286.00","150","","","Percent of Total Billed Charges","neg_dollar:$442.17;150% of Medicaid interim rate","228.80","80","","","Percent of Total Billed Charges","neg_dollar:$228.80;Percent of Total Billed Charges","263.12","92","","","Percent of Total Billed Charges","neg_dollar:$263.12","148.72","52","","","Percent of Total Billed Charges","neg_dollar:$148.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","148.72","52","","","Percent of Total Billed Charges","neg_dollar:$148.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","148.00","286.00",""
"PULSE OX SGL","94760","CPT","90000169","CDM","460","RC","","Facility","Outpatient","","","103","82.40","103.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","53.56","52","","","Percent of Total Billed Charges","neg_dollar:$53.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","103.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","53.56","52","","","Percent of Total Billed Charges","neg_dollar:$53.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","53.56","52","","","Percent of Total Billed Charges","neg_dollar:$53.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","53.56","52","","","Percent of Total Billed Charges","neg_dollar:$53.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.58","86","","","Percent of Total Billed Charges","neg_dollar:$88.58","72.10","70","","","Percent of Total Billed Charges","neg_dollar:$72.10","53.56","52","","","Percent of Total Billed Charges","neg_dollar:$53.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","60.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$60.51;102% of Medicaid interim rate","77.25","75","","","Percent of Total Billed Charges","neg_dollar:$77.25","88.58","86","","","Percent of Total Billed Charges","neg_dollar:$88.58","72.10","70","","","Percent of Total Billed Charges","neg_dollar:$72.10","58.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$58.70;103.5% of Medicaid interim rate","103.00","150","","","Percent of Total Billed Charges","neg_dollar:$159.24;150% of Medicaid interim rate","82.40","80","","","Percent of Total Billed Charges","neg_dollar:$82.40;Percent of Total Billed Charges","94.76","92","","","Percent of Total Billed Charges","neg_dollar:$94.76","53.56","52","","","Percent of Total Billed Charges","neg_dollar:$53.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","53.56","52","","","Percent of Total Billed Charges","neg_dollar:$53.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","53.00","103.00",""
"PULSE OX MULTIPLE","94761","CPT","90000081","CDM","460","RC","","Facility","Outpatient","","","205","164.00","205.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","205.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","176.30","86","","","Percent of Total Billed Charges","neg_dollar:$176.30","143.50","70","","","Percent of Total Billed Charges","neg_dollar:$143.50","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","120.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$120.43;102% of Medicaid interim rate","153.75","75","","","Percent of Total Billed Charges","neg_dollar:$153.75","176.30","86","","","Percent of Total Billed Charges","neg_dollar:$176.30","143.50","70","","","Percent of Total Billed Charges","neg_dollar:$143.50","116.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$116.85;103.5% of Medicaid interim rate","205.00","150","","","Percent of Total Billed Charges","neg_dollar:$316.94;150% of Medicaid interim rate","164.00","80","","","Percent of Total Billed Charges","neg_dollar:$164;Percent of Total Billed Charges","188.60","92","","","Percent of Total Billed Charges","neg_dollar:$188.60","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","106.00","205.00",""
"CONTINUOUS PULSE OX","94762","CPT","90000082","CDM","460","RC","","Facility","Outpatient","","","423","338.40","423.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","423.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","363.78","86","","","Percent of Total Billed Charges","neg_dollar:$363.78","296.09","70","","","Percent of Total Billed Charges","neg_dollar:$296.09","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","248.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$248.51;102% of Medicaid interim rate","317.25","75","","","Percent of Total Billed Charges","neg_dollar:$317.25","363.78","86","","","Percent of Total Billed Charges","neg_dollar:$363.78","296.09","70","","","Percent of Total Billed Charges","neg_dollar:$296.09","241.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$241.10;103.5% of Medicaid interim rate","423.00","150","","","Percent of Total Billed Charges","neg_dollar:$653.97;150% of Medicaid interim rate","338.40","80","","","Percent of Total Billed Charges","neg_dollar:$338.40;Percent of Total Billed Charges","389.16","92","","","Percent of Total Billed Charges","neg_dollar:$389.16","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","219.96","52","","","Percent of Total Billed Charges","neg_dollar:$219.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","219.00","423.00",""
"UNLISTED PULMONARY SERVICE","94799","CPT","90000705","CDM","460","RC","","Facility","Outpatient","","","193","154.40","193.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","100.36","52","","","Percent of Total Billed Charges","neg_dollar:$100.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","193.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","100.36","52","","","Percent of Total Billed Charges","neg_dollar:$100.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","100.36","52","","","Percent of Total Billed Charges","neg_dollar:$100.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","100.36","52","","","Percent of Total Billed Charges","neg_dollar:$100.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.98","86","","","Percent of Total Billed Charges","neg_dollar:$165.98","135.10","70","","","Percent of Total Billed Charges","neg_dollar:$135.10","100.36","52","","","Percent of Total Billed Charges","neg_dollar:$100.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","113.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$113.38;102% of Medicaid interim rate","144.75","75","","","Percent of Total Billed Charges","neg_dollar:$144.75","165.98","86","","","Percent of Total Billed Charges","neg_dollar:$165.98","135.10","70","","","Percent of Total Billed Charges","neg_dollar:$135.10","110.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$110;103.5% of Medicaid interim rate","193.00","150","","","Percent of Total Billed Charges","neg_dollar:$298.38;150% of Medicaid interim rate","154.40","80","","","Percent of Total Billed Charges","neg_dollar:$154.40;Percent of Total Billed Charges","177.56","92","","","Percent of Total Billed Charges","neg_dollar:$177.56","100.36","52","","","Percent of Total Billed Charges","neg_dollar:$100.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","100.36","52","","","Percent of Total Billed Charges","neg_dollar:$100.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","100.00","193.00",""
"SLEEP STUDY UNATTENDED","95800","CPT","90000793","CDM","740","RC","","Facility","Outpatient","","","733","586.40","733.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","733.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","630.38","86","","","Percent of Total Billed Charges","neg_dollar:$630.38","513.10","70","","","Percent of Total Billed Charges","neg_dollar:$513.10","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","430.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$430.63;102% of Medicaid interim rate","549.75","75","","","Percent of Total Billed Charges","neg_dollar:$549.75","630.38","86","","","Percent of Total Billed Charges","neg_dollar:$630.38","513.10","70","","","Percent of Total Billed Charges","neg_dollar:$513.10","417.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$417.80;103.5% of Medicaid interim rate","733.00","150","","","Percent of Total Billed Charges","neg_dollar:$1133.25;150% of Medicaid interim rate","586.40","80","","","Percent of Total Billed Charges","neg_dollar:$586.40;Percent of Total Billed Charges","674.36","92","","","Percent of Total Billed Charges","neg_dollar:$674.36","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","381.00","733.00",""
"MSLT/MWT; GLOBAL","95805","CPT","90000327","CDM","740","RC","TC","Facility","Outpatient","","","3443","2754.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1790.36","52","","","Percent of Total Billed Charges","neg_dollar:$1790.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1790.36","52","","","Percent of Total Billed Charges","neg_dollar:$1790.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1790.36","52","","","Percent of Total Billed Charges","neg_dollar:$1790.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1790.36","52","","","Percent of Total Billed Charges","neg_dollar:$1790.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","2960.98","86","","","Percent of Total Billed Charges","neg_dollar:$2960.98","2410.10","70","","","Percent of Total Billed Charges","neg_dollar:$2410.10","1790.36","52","","","Percent of Total Billed Charges","neg_dollar:$1790.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","2022.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$2022.75;102% of Medicaid interim rate","2582.25","75","","","Percent of Total Billed Charges","neg_dollar:$2582.25","2960.98","86","","","Percent of Total Billed Charges","neg_dollar:$2960.98","2410.10","70","","","Percent of Total Billed Charges","neg_dollar:$2410.10","1962.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$1962.50;103.5% of Medicaid interim rate","3443.00","150","","","Percent of Total Billed Charges","neg_dollar:$5323.05;150% of Medicaid interim rate","2754.40","80","","","Percent of Total Billed Charges","neg_dollar:$2754.40;Percent of Total Billed Charges","3167.56","92","","","Percent of Total Billed Charges","neg_dollar:$3167.56","1790.36","52","","","Percent of Total Billed Charges","neg_dollar:$1790.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","1790.36","52","","","Percent of Total Billed Charges","neg_dollar:$1790.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3443.00",""
"PSS W 4/> PARAM W TECH 6+ YRS","95810","CPT","90000328","CDM","740","RC","","Facility","Outpatient","","","3787","3029.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","3256.82","86","","","Percent of Total Billed Charges","neg_dollar:$3256.82","2650.89","70","","","Percent of Total Billed Charges","neg_dollar:$2650.89","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","2224.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$2224.85;102% of Medicaid interim rate","2840.25","75","","","Percent of Total Billed Charges","neg_dollar:$2840.25","3256.82","86","","","Percent of Total Billed Charges","neg_dollar:$3256.82","2650.89","70","","","Percent of Total Billed Charges","neg_dollar:$2650.89","2158.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$2158.58;103.5% of Medicaid interim rate","3787.00","150","","","Percent of Total Billed Charges","neg_dollar:$5854.89;150% of Medicaid interim rate","3029.60","80","","","Percent of Total Billed Charges","neg_dollar:$3029.60;Percent of Total Billed Charges","3484.04","92","","","Percent of Total Billed Charges","neg_dollar:$3484.04","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1969.24","52","","","Percent of Total Billed Charges","neg_dollar:$1969.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3787.00",""
"PSS W 4/> PARAM W CPAP/BIPAP 6+ YRS","95811","CPT","90000329","CDM","740","RC","","Facility","Outpatient","","","4305","3444.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2238.60","52","","","Percent of Total Billed Charges","neg_dollar:$2238.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2238.60","52","","","Percent of Total Billed Charges","neg_dollar:$2238.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","2238.60","52","","","Percent of Total Billed Charges","neg_dollar:$2238.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","2238.60","52","","","Percent of Total Billed Charges","neg_dollar:$2238.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","3702.29","86","","","Percent of Total Billed Charges","neg_dollar:$3702.29","3013.50","70","","","Percent of Total Billed Charges","neg_dollar:$3013.50","2238.60","52","","","Percent of Total Billed Charges","neg_dollar:$2238.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","2529.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$2529.18;102% of Medicaid interim rate","3228.75","75","","","Percent of Total Billed Charges","neg_dollar:$3228.75","3702.29","86","","","Percent of Total Billed Charges","neg_dollar:$3702.29","3013.50","70","","","Percent of Total Billed Charges","neg_dollar:$3013.50","2453.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$2453.85;103.5% of Medicaid interim rate","4305.00","150","","","Percent of Total Billed Charges","neg_dollar:$6655.74;150% of Medicaid interim rate","3444.00","80","","","Percent of Total Billed Charges","neg_dollar:$3444;Percent of Total Billed Charges","3960.60","92","","","Percent of Total Billed Charges","neg_dollar:$3960.60","2238.60","52","","","Percent of Total Billed Charges","neg_dollar:$2238.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","2238.60","52","","","Percent of Total Billed Charges","neg_dollar:$2238.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4305.00",""
"CANALITH REPOSITIONING PROCEDURE","95992","CPT","97000137","CDM","420","RC","","Facility","Outpatient","","","160","128.00","160.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","83.20","52","","","Percent of Total Billed Charges","neg_dollar:$83.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","160.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","83.20","52","","","Percent of Total Billed Charges","neg_dollar:$83.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.20","52","","","Percent of Total Billed Charges","neg_dollar:$83.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.20","52","","","Percent of Total Billed Charges","neg_dollar:$83.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","137.60","86","","","Percent of Total Billed Charges","neg_dollar:$137.60","112.00","70","","","Percent of Total Billed Charges","neg_dollar:$112","83.20","52","","","Percent of Total Billed Charges","neg_dollar:$83.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","93.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$93.99;102% of Medicaid interim rate","120.00","75","","","Percent of Total Billed Charges","neg_dollar:$120","137.60","86","","","Percent of Total Billed Charges","neg_dollar:$137.60","112.00","70","","","Percent of Total Billed Charges","neg_dollar:$112","91.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$91.19;103.5% of Medicaid interim rate","160.00","150","","","Percent of Total Billed Charges","neg_dollar:$247.36;150% of Medicaid interim rate","128.00","80","","","Percent of Total Billed Charges","neg_dollar:$128;Percent of Total Billed Charges","147.20","92","","","Percent of Total Billed Charges","neg_dollar:$147.20","83.20","52","","","Percent of Total Billed Charges","neg_dollar:$83.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","83.20","52","","","Percent of Total Billed Charges","neg_dollar:$83.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","83.00","160.00",""
"COGNITIVE TEST BY HC PRO","96125","CPT","97000064","CDM","440","RC","","Facility","Outpatient","","","313","250.40","313.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","313.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","269.18","86","","","Percent of Total Billed Charges","neg_dollar:$269.18","219.10","70","","","Percent of Total Billed Charges","neg_dollar:$219.10","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","183.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$183.88;102% of Medicaid interim rate","234.75","75","","","Percent of Total Billed Charges","neg_dollar:$234.75","269.18","86","","","Percent of Total Billed Charges","neg_dollar:$269.18","219.10","70","","","Percent of Total Billed Charges","neg_dollar:$219.10","178.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$178.41;103.5% of Medicaid interim rate","313.00","150","","","Percent of Total Billed Charges","neg_dollar:$483.91;150% of Medicaid interim rate","250.40","80","","","Percent of Total Billed Charges","neg_dollar:$250.40;Percent of Total Billed Charges","287.96","92","","","Percent of Total Billed Charges","neg_dollar:$287.96","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.76","52","","","Percent of Total Billed Charges","neg_dollar:$162.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.00","313.00",""
"NEUROPSYCH TST EVAL PHYS/QHP 1ST HR","96132","CPT","90001172","CDM","918","RC","","Facility","Outpatient","","","517","413.60","517.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","268.84","52","","","Percent of Total Billed Charges","neg_dollar:$268.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","517.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","268.84","52","","","Percent of Total Billed Charges","neg_dollar:$268.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","268.84","52","","","Percent of Total Billed Charges","neg_dollar:$268.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","268.84","52","","","Percent of Total Billed Charges","neg_dollar:$268.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","444.62","86","","","Percent of Total Billed Charges","neg_dollar:$444.62","361.90","70","","","Percent of Total Billed Charges","neg_dollar:$361.90","268.84","52","","","Percent of Total Billed Charges","neg_dollar:$268.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","303.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$303.73;102% of Medicaid interim rate","387.75","75","","","Percent of Total Billed Charges","neg_dollar:$387.75","444.62","86","","","Percent of Total Billed Charges","neg_dollar:$444.62","361.90","70","","","Percent of Total Billed Charges","neg_dollar:$361.90","294.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$294.69;103.5% of Medicaid interim rate","517.00","150","","","Percent of Total Billed Charges","neg_dollar:$799.30;150% of Medicaid interim rate","413.60","80","","","Percent of Total Billed Charges","neg_dollar:$413.60;Percent of Total Billed Charges","475.64","92","","","Percent of Total Billed Charges","neg_dollar:$475.64","268.84","52","","","Percent of Total Billed Charges","neg_dollar:$268.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","268.84","52","","","Percent of Total Billed Charges","neg_dollar:$268.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","268.00","517.00",""
"NEUROPSYCH TST EVAL PHYS/QHP EA ADDL HR","96133","CPT","90001173","CDM","918","RC","","Facility","Outpatient","","","392","313.60","392.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","203.84","52","","","Percent of Total Billed Charges","neg_dollar:$203.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","392.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","203.84","52","","","Percent of Total Billed Charges","neg_dollar:$203.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","203.84","52","","","Percent of Total Billed Charges","neg_dollar:$203.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","203.84","52","","","Percent of Total Billed Charges","neg_dollar:$203.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","337.12","86","","","Percent of Total Billed Charges","neg_dollar:$337.12","274.40","70","","","Percent of Total Billed Charges","neg_dollar:$274.40","203.84","52","","","Percent of Total Billed Charges","neg_dollar:$203.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","230.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$230.29;102% of Medicaid interim rate","294.00","75","","","Percent of Total Billed Charges","neg_dollar:$294","337.12","86","","","Percent of Total Billed Charges","neg_dollar:$337.12","274.40","70","","","Percent of Total Billed Charges","neg_dollar:$274.40","223.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$223.43;103.5% of Medicaid interim rate","392.00","150","","","Percent of Total Billed Charges","neg_dollar:$606.05;150% of Medicaid interim rate","313.60","80","","","Percent of Total Billed Charges","neg_dollar:$313.60;Percent of Total Billed Charges","360.64","92","","","Percent of Total Billed Charges","neg_dollar:$360.64","203.84","52","","","Percent of Total Billed Charges","neg_dollar:$203.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","203.84","52","","","Percent of Total Billed Charges","neg_dollar:$203.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","203.00","392.00",""
"PSYCH/NEUROPSYCH TST PHY/QHP 1ST 30 MIN","96136","CPT","90001176","CDM","918","RC","","Facility","Outpatient","","","179","143.20","179.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","179.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","153.94","86","","","Percent of Total Billed Charges","neg_dollar:$153.94","125.30","70","","","Percent of Total Billed Charges","neg_dollar:$125.30","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","105.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$105.16;102% of Medicaid interim rate","134.25","75","","","Percent of Total Billed Charges","neg_dollar:$134.25","153.94","86","","","Percent of Total Billed Charges","neg_dollar:$153.94","125.30","70","","","Percent of Total Billed Charges","neg_dollar:$125.30","102.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$102.02;103.5% of Medicaid interim rate","179.00","150","","","Percent of Total Billed Charges","neg_dollar:$276.74;150% of Medicaid interim rate","143.20","80","","","Percent of Total Billed Charges","neg_dollar:$143.20;Percent of Total Billed Charges","164.68","92","","","Percent of Total Billed Charges","neg_dollar:$164.68","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","93.00","179.00",""
"PSYCH/NEUROPSYCH TST PHY/QHP EA ADDL 30 MIN","96137","CPT","90001177","CDM","918","RC","","Facility","Outpatient","","","165","132.00","165.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","85.80","52","","","Percent of Total Billed Charges","neg_dollar:$85.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","165.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","85.80","52","","","Percent of Total Billed Charges","neg_dollar:$85.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","85.80","52","","","Percent of Total Billed Charges","neg_dollar:$85.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","85.80","52","","","Percent of Total Billed Charges","neg_dollar:$85.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","141.90","86","","","Percent of Total Billed Charges","neg_dollar:$141.90","115.49","70","","","Percent of Total Billed Charges","neg_dollar:$115.49","85.80","52","","","Percent of Total Billed Charges","neg_dollar:$85.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","96.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$96.93;102% of Medicaid interim rate","123.75","75","","","Percent of Total Billed Charges","neg_dollar:$123.75","141.90","86","","","Percent of Total Billed Charges","neg_dollar:$141.90","115.49","70","","","Percent of Total Billed Charges","neg_dollar:$115.49","94.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$94.05;103.5% of Medicaid interim rate","165.00","150","","","Percent of Total Billed Charges","neg_dollar:$255.09;150% of Medicaid interim rate","132.00","80","","","Percent of Total Billed Charges","neg_dollar:$132;Percent of Total Billed Charges","151.80","92","","","Percent of Total Billed Charges","neg_dollar:$151.80","85.80","52","","","Percent of Total Billed Charges","neg_dollar:$85.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","85.80","52","","","Percent of Total Billed Charges","neg_dollar:$85.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","85.00","165.00",""
"HYDRATION IV INFUSION INIT 31-60 MIN","96360","CPT","90000090","CDM","260","RC","","Facility","Outpatient","","","347","277.60","347.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","347.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","298.42","86","","","Percent of Total Billed Charges","neg_dollar:$298.42","242.89","70","","","Percent of Total Billed Charges","neg_dollar:$242.89","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","203.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$203.86;102% of Medicaid interim rate","260.25","75","","","Percent of Total Billed Charges","neg_dollar:$260.25","298.42","86","","","Percent of Total Billed Charges","neg_dollar:$298.42","242.89","70","","","Percent of Total Billed Charges","neg_dollar:$242.89","197.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$197.79;103.5% of Medicaid interim rate","347.00","150","","","Percent of Total Billed Charges","neg_dollar:$536.47;150% of Medicaid interim rate","277.60","80","","","Percent of Total Billed Charges","neg_dollar:$277.60;Percent of Total Billed Charges","319.24","92","","","Percent of Total Billed Charges","neg_dollar:$319.24","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","180.44","52","","","Percent of Total Billed Charges","neg_dollar:$180.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","180.00","347.00",""
"HYDRATE IV INFUSION EA ADDTL HR","96361","CPT","90000091","CDM","260","RC","","Facility","Outpatient","","","132","105.60","132.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","132.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","113.52","86","","","Percent of Total Billed Charges","neg_dollar:$113.52","92.39","70","","","Percent of Total Billed Charges","neg_dollar:$92.39","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","77.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$77.54;102% of Medicaid interim rate","99.00","75","","","Percent of Total Billed Charges","neg_dollar:$99","113.52","86","","","Percent of Total Billed Charges","neg_dollar:$113.52","92.39","70","","","Percent of Total Billed Charges","neg_dollar:$92.39","75.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$75.24;103.5% of Medicaid interim rate","132.00","150","","","Percent of Total Billed Charges","neg_dollar:$204.07;150% of Medicaid interim rate","105.60","80","","","Percent of Total Billed Charges","neg_dollar:$105.60;Percent of Total Billed Charges","121.44","92","","","Percent of Total Billed Charges","neg_dollar:$121.44","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","68.00","132.00",""
"THER/PROPH/DX IV INF INIT UP TO 1HR","96365","CPT","90000092","CDM","260","RC","","Facility","Outpatient","","","576","460.80","576.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","299.52","52","","","Percent of Total Billed Charges","neg_dollar:$299.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","576.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","299.52","52","","","Percent of Total Billed Charges","neg_dollar:$299.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","299.52","52","","","Percent of Total Billed Charges","neg_dollar:$299.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","299.52","52","","","Percent of Total Billed Charges","neg_dollar:$299.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","495.36","86","","","Percent of Total Billed Charges","neg_dollar:$495.36","403.20","70","","","Percent of Total Billed Charges","neg_dollar:$403.20","299.52","52","","","Percent of Total Billed Charges","neg_dollar:$299.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","338.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$338.39;102% of Medicaid interim rate","432.00","75","","","Percent of Total Billed Charges","neg_dollar:$432","495.36","86","","","Percent of Total Billed Charges","neg_dollar:$495.36","403.20","70","","","Percent of Total Billed Charges","neg_dollar:$403.20","328.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$328.32;103.5% of Medicaid interim rate","576.00","150","","","Percent of Total Billed Charges","neg_dollar:$890.52;150% of Medicaid interim rate","460.80","80","","","Percent of Total Billed Charges","neg_dollar:$460.80;Percent of Total Billed Charges","529.92","92","","","Percent of Total Billed Charges","neg_dollar:$529.92","299.52","52","","","Percent of Total Billed Charges","neg_dollar:$299.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","299.52","52","","","Percent of Total Billed Charges","neg_dollar:$299.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","299.00","576.00",""
"THER/PROPH/DX IV INF EA ADDTL HR","96366","CPT","90000093","CDM","260","RC","","Facility","Outpatient","","","120","96.00","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","70.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$70.49;102% of Medicaid interim rate","90.00","75","","","Percent of Total Billed Charges","neg_dollar:$90","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","68.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.39;103.5% of Medicaid interim rate","120.00","150","","","Percent of Total Billed Charges","neg_dollar:$185.52;150% of Medicaid interim rate","96.00","80","","","Percent of Total Billed Charges","neg_dollar:$96;Percent of Total Billed Charges","110.40","92","","","Percent of Total Billed Charges","neg_dollar:$110.40","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","120.00",""
"TX/PROPH/DX ADDL SEQ IV INF UP TO 1HR","96367","CPT","90000094","CDM","260","RC","","Facility","Outpatient","","","170","136.00","170.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","170.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","146.20","86","","","Percent of Total Billed Charges","neg_dollar:$146.20","118.99","70","","","Percent of Total Billed Charges","neg_dollar:$118.99","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","99.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$99.87;102% of Medicaid interim rate","127.50","75","","","Percent of Total Billed Charges","neg_dollar:$127.50","146.20","86","","","Percent of Total Billed Charges","neg_dollar:$146.20","118.99","70","","","Percent of Total Billed Charges","neg_dollar:$118.99","96.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$96.89;103.5% of Medicaid interim rate","170.00","150","","","Percent of Total Billed Charges","neg_dollar:$262.82;150% of Medicaid interim rate","136.00","80","","","Percent of Total Billed Charges","neg_dollar:$136;Percent of Total Billed Charges","156.40","92","","","Percent of Total Billed Charges","neg_dollar:$156.40","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","88.00","170.00",""
"THER/DX CONCURRENT INF","96368","CPT","90000095","CDM","260","RC","","Facility","Outpatient","","","132","105.60","132.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","132.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","113.52","86","","","Percent of Total Billed Charges","neg_dollar:$113.52","92.39","70","","","Percent of Total Billed Charges","neg_dollar:$92.39","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","77.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$77.54;102% of Medicaid interim rate","99.00","75","","","Percent of Total Billed Charges","neg_dollar:$99","113.52","86","","","Percent of Total Billed Charges","neg_dollar:$113.52","92.39","70","","","Percent of Total Billed Charges","neg_dollar:$92.39","75.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$75.24;103.5% of Medicaid interim rate","132.00","150","","","Percent of Total Billed Charges","neg_dollar:$204.07;150% of Medicaid interim rate","105.60","80","","","Percent of Total Billed Charges","neg_dollar:$105.60;Percent of Total Billed Charges","121.44","92","","","Percent of Total Billed Charges","neg_dollar:$121.44","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","68.64","52","","","Percent of Total Billed Charges","neg_dollar:$68.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","68.00","132.00",""
"THER/PROPH/DIAG INJ SC/IM","96372","CPT","90000113","CDM","260","RC","","Facility","Outpatient","","","120","96.00","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","120.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","70.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$70.49;102% of Medicaid interim rate","90.00","75","","","Percent of Total Billed Charges","neg_dollar:$90","103.20","86","","","Percent of Total Billed Charges","neg_dollar:$103.20","84.00","70","","","Percent of Total Billed Charges","neg_dollar:$84","68.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.39;103.5% of Medicaid interim rate","120.00","150","","","Percent of Total Billed Charges","neg_dollar:$185.52;150% of Medicaid interim rate","96.00","80","","","Percent of Total Billed Charges","neg_dollar:$96;Percent of Total Billed Charges","110.40","92","","","Percent of Total Billed Charges","neg_dollar:$110.40","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.40","52","","","Percent of Total Billed Charges","neg_dollar:$62.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","120.00",""
"THER/PRO/DX INJ IV PUSH","96374","CPT","90000097","CDM","260","RC","","Facility","Outpatient","","","204","163.20","204.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","106.08","52","","","Percent of Total Billed Charges","neg_dollar:$106.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","204.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","106.08","52","","","Percent of Total Billed Charges","neg_dollar:$106.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","106.08","52","","","Percent of Total Billed Charges","neg_dollar:$106.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","106.08","52","","","Percent of Total Billed Charges","neg_dollar:$106.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","175.44","86","","","Percent of Total Billed Charges","neg_dollar:$175.44","142.79","70","","","Percent of Total Billed Charges","neg_dollar:$142.79","106.08","52","","","Percent of Total Billed Charges","neg_dollar:$106.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","119.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$119.84;102% of Medicaid interim rate","153.00","75","","","Percent of Total Billed Charges","neg_dollar:$153","175.44","86","","","Percent of Total Billed Charges","neg_dollar:$175.44","142.79","70","","","Percent of Total Billed Charges","neg_dollar:$142.79","116.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$116.27;103.5% of Medicaid interim rate","204.00","150","","","Percent of Total Billed Charges","neg_dollar:$315.39;150% of Medicaid interim rate","163.20","80","","","Percent of Total Billed Charges","neg_dollar:$163.20;Percent of Total Billed Charges","187.68","92","","","Percent of Total Billed Charges","neg_dollar:$187.68","106.08","52","","","Percent of Total Billed Charges","neg_dollar:$106.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","106.08","52","","","Percent of Total Billed Charges","neg_dollar:$106.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","106.00","204.00",""
"TX/PRO/DX INJ NEW DRG ADD-ON","96375","CPT","90000098","CDM","260","RC","","Facility","Outpatient","","","162","129.60","162.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","162.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","139.32","86","","","Percent of Total Billed Charges","neg_dollar:$139.32","113.39","70","","","Percent of Total Billed Charges","neg_dollar:$113.39","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","95.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$95.17;102% of Medicaid interim rate","121.50","75","","","Percent of Total Billed Charges","neg_dollar:$121.50","139.32","86","","","Percent of Total Billed Charges","neg_dollar:$139.32","113.39","70","","","Percent of Total Billed Charges","neg_dollar:$113.39","92.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$92.33;103.5% of Medicaid interim rate","162.00","150","","","Percent of Total Billed Charges","neg_dollar:$250.46;150% of Medicaid interim rate","129.60","80","","","Percent of Total Billed Charges","neg_dollar:$129.60;Percent of Total Billed Charges","149.04","92","","","Percent of Total Billed Charges","neg_dollar:$149.04","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","84.00","162.00",""
"TX/PRO/DX INJ SAME DRG ADD-ON","96376","CPT","90000099","CDM","260","RC","","Facility","Outpatient","","","97","77.60","97.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","50.44","52","","","Percent of Total Billed Charges","neg_dollar:$50.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","97.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","50.44","52","","","Percent of Total Billed Charges","neg_dollar:$50.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.44","52","","","Percent of Total Billed Charges","neg_dollar:$50.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.44","52","","","Percent of Total Billed Charges","neg_dollar:$50.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.42","86","","","Percent of Total Billed Charges","neg_dollar:$83.42","67.89","70","","","Percent of Total Billed Charges","neg_dollar:$67.89","50.44","52","","","Percent of Total Billed Charges","neg_dollar:$50.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","56.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.98;102% of Medicaid interim rate","72.75","75","","","Percent of Total Billed Charges","neg_dollar:$72.75","83.42","86","","","Percent of Total Billed Charges","neg_dollar:$83.42","67.89","70","","","Percent of Total Billed Charges","neg_dollar:$67.89","55.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.28;103.5% of Medicaid interim rate","97.00","150","","","Percent of Total Billed Charges","neg_dollar:$149.96;150% of Medicaid interim rate","77.60","80","","","Percent of Total Billed Charges","neg_dollar:$77.60;Percent of Total Billed Charges","89.24","92","","","Percent of Total Billed Charges","neg_dollar:$89.24","50.44","52","","","Percent of Total Billed Charges","neg_dollar:$50.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","50.44","52","","","Percent of Total Billed Charges","neg_dollar:$50.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","50.00","97.00",""
"IRRIG DRUG DELIVERY DEVICE","96523","CPT","90000217","CDM","761","RC","","Facility","Outpatient","","","190","152.00","190.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","98.80","52","","","Percent of Total Billed Charges","neg_dollar:$98.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","190.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","98.80","52","","","Percent of Total Billed Charges","neg_dollar:$98.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","98.80","52","","","Percent of Total Billed Charges","neg_dollar:$98.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","98.80","52","","","Percent of Total Billed Charges","neg_dollar:$98.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","163.40","86","","","Percent of Total Billed Charges","neg_dollar:$163.40","133.00","70","","","Percent of Total Billed Charges","neg_dollar:$133","98.80","52","","","Percent of Total Billed Charges","neg_dollar:$98.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","111.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$111.62;102% of Medicaid interim rate","142.50","75","","","Percent of Total Billed Charges","neg_dollar:$142.50","163.40","86","","","Percent of Total Billed Charges","neg_dollar:$163.40","133.00","70","","","Percent of Total Billed Charges","neg_dollar:$133","108.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$108.30;103.5% of Medicaid interim rate","190.00","150","","","Percent of Total Billed Charges","neg_dollar:$293.74;150% of Medicaid interim rate","152.00","80","","","Percent of Total Billed Charges","neg_dollar:$152;Percent of Total Billed Charges","174.80","92","","","Percent of Total Billed Charges","neg_dollar:$174.80","98.80","52","","","Percent of Total Billed Charges","neg_dollar:$98.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","98.80","52","","","Percent of Total Billed Charges","neg_dollar:$98.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","98.00","190.00",""
"MODALITY MECHANICAL TRACTION","97012","CPT","97000005","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"NON WND ELECT STIM","97014","CPT","97000050","CDM","420","RC","","Facility","Outpatient","","","101","80.80","101.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","101.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","86.86","86","","","Percent of Total Billed Charges","neg_dollar:$86.86","70.69","70","","","Percent of Total Billed Charges","neg_dollar:$70.69","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","59.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.33;102% of Medicaid interim rate","75.75","75","","","Percent of Total Billed Charges","neg_dollar:$75.75","86.86","86","","","Percent of Total Billed Charges","neg_dollar:$86.86","70.69","70","","","Percent of Total Billed Charges","neg_dollar:$70.69","57.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.56;103.5% of Medicaid interim rate","101.00","150","","","Percent of Total Billed Charges","neg_dollar:$156.15;150% of Medicaid interim rate","80.80","80","","","Percent of Total Billed Charges","neg_dollar:$80.80;Percent of Total Billed Charges","92.92","92","","","Percent of Total Billed Charges","neg_dollar:$92.92","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","101.00",""
"MODALITY VASOPNEUMATIC DEVICES","97016","CPT","97000020","CDM","420","RC","","Facility","Outpatient","","","143","114.40","143.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","143.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","122.98","86","","","Percent of Total Billed Charges","neg_dollar:$122.98","100.10","70","","","Percent of Total Billed Charges","neg_dollar:$100.10","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","84.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$84.01;102% of Medicaid interim rate","107.25","75","","","Percent of Total Billed Charges","neg_dollar:$107.25","122.98","86","","","Percent of Total Billed Charges","neg_dollar:$122.98","100.10","70","","","Percent of Total Billed Charges","neg_dollar:$100.10","81.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$81.50;103.5% of Medicaid interim rate","143.00","150","","","Percent of Total Billed Charges","neg_dollar:$221.08;150% of Medicaid interim rate","114.40","80","","","Percent of Total Billed Charges","neg_dollar:$114.40;Percent of Total Billed Charges","131.56","92","","","Percent of Total Billed Charges","neg_dollar:$131.56","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","74.36","52","","","Percent of Total Billed Charges","neg_dollar:$74.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","74.00","143.00",""
"MODALITY PARAFFIN BATH","97018","CPT","97000021","CDM","420","RC","","Facility","Outpatient","","","128","102.40","128.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","128.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.08","86","","","Percent of Total Billed Charges","neg_dollar:$110.08","89.60","70","","","Percent of Total Billed Charges","neg_dollar:$89.60","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","75.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$75.19;102% of Medicaid interim rate","96.00","75","","","Percent of Total Billed Charges","neg_dollar:$96","110.08","86","","","Percent of Total Billed Charges","neg_dollar:$110.08","89.60","70","","","Percent of Total Billed Charges","neg_dollar:$89.60","72.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$72.96;103.5% of Medicaid interim rate","128.00","150","","","Percent of Total Billed Charges","neg_dollar:$197.89;150% of Medicaid interim rate","102.40","80","","","Percent of Total Billed Charges","neg_dollar:$102.40;Percent of Total Billed Charges","117.76","92","","","Percent of Total Billed Charges","neg_dollar:$117.76","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","66.00","128.00",""
"MODALITY M ELECTR STIM EA 15M","97032","CPT","97000024","CDM","420","RC","","Facility","Outpatient","","","128","102.40","128.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","128.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.08","86","","","Percent of Total Billed Charges","neg_dollar:$110.08","89.60","70","","","Percent of Total Billed Charges","neg_dollar:$89.60","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","75.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$75.19;102% of Medicaid interim rate","96.00","75","","","Percent of Total Billed Charges","neg_dollar:$96","110.08","86","","","Percent of Total Billed Charges","neg_dollar:$110.08","89.60","70","","","Percent of Total Billed Charges","neg_dollar:$89.60","72.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$72.96;103.5% of Medicaid interim rate","128.00","150","","","Percent of Total Billed Charges","neg_dollar:$197.89;150% of Medicaid interim rate","102.40","80","","","Percent of Total Billed Charges","neg_dollar:$102.40;Percent of Total Billed Charges","117.76","92","","","Percent of Total Billed Charges","neg_dollar:$117.76","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","66.56","52","","","Percent of Total Billed Charges","neg_dollar:$66.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","66.00","128.00",""
"MODALITY IONTOPHORESIS EA 15M","97033","CPT","97000025","CDM","420","RC","","Facility","Outpatient","","","135","108.00","135.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","135.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","116.10","86","","","Percent of Total Billed Charges","neg_dollar:$116.10","94.50","70","","","Percent of Total Billed Charges","neg_dollar:$94.50","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","79.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$79.31;102% of Medicaid interim rate","101.25","75","","","Percent of Total Billed Charges","neg_dollar:$101.25","116.10","86","","","Percent of Total Billed Charges","neg_dollar:$116.10","94.50","70","","","Percent of Total Billed Charges","neg_dollar:$94.50","76.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$76.94;103.5% of Medicaid interim rate","135.00","150","","","Percent of Total Billed Charges","neg_dollar:$208.71;150% of Medicaid interim rate","108.00","80","","","Percent of Total Billed Charges","neg_dollar:$108;Percent of Total Billed Charges","124.20","92","","","Percent of Total Billed Charges","neg_dollar:$124.20","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","70.00","135.00",""
"MODALITY CONTRAST BATHS EA 15M","97034","CPT","97000026","CDM","420","RC","","Facility","Outpatient","","","110","88.00","110.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","110.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","94.60","86","","","Percent of Total Billed Charges","neg_dollar:$94.60","77.00","70","","","Percent of Total Billed Charges","neg_dollar:$77","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","64.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.62;102% of Medicaid interim rate","82.50","75","","","Percent of Total Billed Charges","neg_dollar:$82.50","94.60","86","","","Percent of Total Billed Charges","neg_dollar:$94.60","77.00","70","","","Percent of Total Billed Charges","neg_dollar:$77","62.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$62.69;103.5% of Medicaid interim rate","110.00","150","","","Percent of Total Billed Charges","neg_dollar:$170.06;150% of Medicaid interim rate","88.00","80","","","Percent of Total Billed Charges","neg_dollar:$88;Percent of Total Billed Charges","101.20","92","","","Percent of Total Billed Charges","neg_dollar:$101.20","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","57.00","110.00",""
"MODALITY ULTRASOUND EA 15M","97035","CPT","97000027","CDM","420","RC","","Facility","Outpatient","","","101","80.80","101.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","101.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","86.86","86","","","Percent of Total Billed Charges","neg_dollar:$86.86","70.69","70","","","Percent of Total Billed Charges","neg_dollar:$70.69","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","59.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.33;102% of Medicaid interim rate","75.75","75","","","Percent of Total Billed Charges","neg_dollar:$75.75","86.86","86","","","Percent of Total Billed Charges","neg_dollar:$86.86","70.69","70","","","Percent of Total Billed Charges","neg_dollar:$70.69","57.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.56;103.5% of Medicaid interim rate","101.00","150","","","Percent of Total Billed Charges","neg_dollar:$156.15;150% of Medicaid interim rate","80.80","80","","","Percent of Total Billed Charges","neg_dollar:$80.80;Percent of Total Billed Charges","92.92","92","","","Percent of Total Billed Charges","neg_dollar:$92.92","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","101.00",""
"THERAP EXERCISE ROM EA 15M","97110","CPT","97000028","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"NEUROMUSCLE RE-EDUC EA 15M","97112","CPT","97000029","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"GAIT TRAINING THERAPY EA 15 MIN","97116","CPT","97000006","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"MASSAGE THERAPY EA 15M","97124","CPT","97000030","CDM","420","RC","","Facility","Outpatient","","","79","63.20","79.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","79.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","67.94","86","","","Percent of Total Billed Charges","neg_dollar:$67.94","55.30","70","","","Percent of Total Billed Charges","neg_dollar:$55.30","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","46.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$46.41;102% of Medicaid interim rate","59.25","75","","","Percent of Total Billed Charges","neg_dollar:$59.25","67.94","86","","","Percent of Total Billed Charges","neg_dollar:$67.94","55.30","70","","","Percent of Total Billed Charges","neg_dollar:$55.30","45.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$45.02;103.5% of Medicaid interim rate","79.00","150","","","Percent of Total Billed Charges","neg_dollar:$122.13;150% of Medicaid interim rate","63.20","80","","","Percent of Total Billed Charges","neg_dollar:$63.20;Percent of Total Billed Charges","72.68","92","","","Percent of Total Billed Charges","neg_dollar:$72.68","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","41.00","79.00",""
"THER IVNTJ COG FUNCJ 1ST 15 MIN","97129","CPT","97000329","CDM","420","RC","","Facility","Outpatient","","","110","88.00","110.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","110.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","94.60","86","","","Percent of Total Billed Charges","neg_dollar:$94.60","77.00","70","","","Percent of Total Billed Charges","neg_dollar:$77","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","64.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.62;102% of Medicaid interim rate","82.50","75","","","Percent of Total Billed Charges","neg_dollar:$82.50","94.60","86","","","Percent of Total Billed Charges","neg_dollar:$94.60","77.00","70","","","Percent of Total Billed Charges","neg_dollar:$77","62.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$62.69;103.5% of Medicaid interim rate","110.00","150","","","Percent of Total Billed Charges","neg_dollar:$170.06;150% of Medicaid interim rate","88.00","80","","","Percent of Total Billed Charges","neg_dollar:$88;Percent of Total Billed Charges","101.20","92","","","Percent of Total Billed Charges","neg_dollar:$101.20","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","57.20","52","","","Percent of Total Billed Charges","neg_dollar:$57.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","57.00","110.00",""
"THER IVNTJ COG FUNCJ EA ADDL 15 MIN","97130","CPT","97000330","CDM","420","RC","","Facility","Outpatient","","","83","66.40","83.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","43.16","52","","","Percent of Total Billed Charges","neg_dollar:$43.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","83.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","43.16","52","","","Percent of Total Billed Charges","neg_dollar:$43.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","43.16","52","","","Percent of Total Billed Charges","neg_dollar:$43.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","43.16","52","","","Percent of Total Billed Charges","neg_dollar:$43.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","71.38","86","","","Percent of Total Billed Charges","neg_dollar:$71.38","58.09","70","","","Percent of Total Billed Charges","neg_dollar:$58.09","43.16","52","","","Percent of Total Billed Charges","neg_dollar:$43.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","48.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$48.76;102% of Medicaid interim rate","62.25","75","","","Percent of Total Billed Charges","neg_dollar:$62.25","71.38","86","","","Percent of Total Billed Charges","neg_dollar:$71.38","58.09","70","","","Percent of Total Billed Charges","neg_dollar:$58.09","47.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$47.30;103.5% of Medicaid interim rate","83.00","150","","","Percent of Total Billed Charges","neg_dollar:$128.32;150% of Medicaid interim rate","66.40","80","","","Percent of Total Billed Charges","neg_dollar:$66.40;Percent of Total Billed Charges","76.36","92","","","Percent of Total Billed Charges","neg_dollar:$76.36","43.16","52","","","Percent of Total Billed Charges","neg_dollar:$43.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","43.16","52","","","Percent of Total Billed Charges","neg_dollar:$43.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","43.00","83.00",""
"MANUAL THERAPY EA 15M","97140","CPT","97000031","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"PT EVAL LOW COMPLEX","97161","CPT","97000301","CDM","424","RC","","Facility","Outpatient","","","213","170.40","213.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","213.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","183.18","86","","","Percent of Total Billed Charges","neg_dollar:$183.18","149.10","70","","","Percent of Total Billed Charges","neg_dollar:$149.10","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","125.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$125.13;102% of Medicaid interim rate","159.75","75","","","Percent of Total Billed Charges","neg_dollar:$159.75","183.18","86","","","Percent of Total Billed Charges","neg_dollar:$183.18","149.10","70","","","Percent of Total Billed Charges","neg_dollar:$149.10","121.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$121.41;103.5% of Medicaid interim rate","213.00","150","","","Percent of Total Billed Charges","neg_dollar:$329.30;150% of Medicaid interim rate","170.40","80","","","Percent of Total Billed Charges","neg_dollar:$170.40;Percent of Total Billed Charges","195.96","92","","","Percent of Total Billed Charges","neg_dollar:$195.96","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","110.00","213.00",""
"PT EVAL MOD COMPLEX","97162","CPT","97000302","CDM","424","RC","","Facility","Outpatient","","","253","202.40","253.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","253.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","217.57","86","","","Percent of Total Billed Charges","neg_dollar:$217.57","177.10","70","","","Percent of Total Billed Charges","neg_dollar:$177.10","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","148.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$148.63;102% of Medicaid interim rate","189.75","75","","","Percent of Total Billed Charges","neg_dollar:$189.75","217.57","86","","","Percent of Total Billed Charges","neg_dollar:$217.57","177.10","70","","","Percent of Total Billed Charges","neg_dollar:$177.10","144.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$144.20;103.5% of Medicaid interim rate","253.00","150","","","Percent of Total Billed Charges","neg_dollar:$391.15;150% of Medicaid interim rate","202.40","80","","","Percent of Total Billed Charges","neg_dollar:$202.40;Percent of Total Billed Charges","232.76","92","","","Percent of Total Billed Charges","neg_dollar:$232.76","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","131.00","253.00",""
"PT EVAL HIGH COMPLEX","97163","CPT","97000303","CDM","424","RC","","Facility","Outpatient","","","297","237.60","297.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","297.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","174.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$174.48;102% of Medicaid interim rate","222.75","75","","","Percent of Total Billed Charges","neg_dollar:$222.75","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","169.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$169.29;103.5% of Medicaid interim rate","297.00","150","","","Percent of Total Billed Charges","neg_dollar:$459.17;150% of Medicaid interim rate","237.60","80","","","Percent of Total Billed Charges","neg_dollar:$237.60;Percent of Total Billed Charges","273.24","92","","","Percent of Total Billed Charges","neg_dollar:$273.24","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","154.00","297.00",""
"PT RE-EVAL EST PLAN CARE","97164","CPT","97000304","CDM","424","RC","","Facility","Outpatient","","","170","136.00","170.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","170.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","146.20","86","","","Percent of Total Billed Charges","neg_dollar:$146.20","118.99","70","","","Percent of Total Billed Charges","neg_dollar:$118.99","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","99.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$99.87;102% of Medicaid interim rate","127.50","75","","","Percent of Total Billed Charges","neg_dollar:$127.50","146.20","86","","","Percent of Total Billed Charges","neg_dollar:$146.20","118.99","70","","","Percent of Total Billed Charges","neg_dollar:$118.99","96.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$96.89;103.5% of Medicaid interim rate","170.00","150","","","Percent of Total Billed Charges","neg_dollar:$262.82;150% of Medicaid interim rate","136.00","80","","","Percent of Total Billed Charges","neg_dollar:$136;Percent of Total Billed Charges","156.40","92","","","Percent of Total Billed Charges","neg_dollar:$156.40","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","88.00","170.00",""
"OT EVAL LOW COMPLEX","97165","CPT","97000305","CDM","434","RC","","Facility","Outpatient","","","213","170.40","213.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","213.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","183.18","86","","","Percent of Total Billed Charges","neg_dollar:$183.18","149.10","70","","","Percent of Total Billed Charges","neg_dollar:$149.10","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","125.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$125.13;102% of Medicaid interim rate","159.75","75","","","Percent of Total Billed Charges","neg_dollar:$159.75","183.18","86","","","Percent of Total Billed Charges","neg_dollar:$183.18","149.10","70","","","Percent of Total Billed Charges","neg_dollar:$149.10","121.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$121.41;103.5% of Medicaid interim rate","213.00","150","","","Percent of Total Billed Charges","neg_dollar:$329.30;150% of Medicaid interim rate","170.40","80","","","Percent of Total Billed Charges","neg_dollar:$170.40;Percent of Total Billed Charges","195.96","92","","","Percent of Total Billed Charges","neg_dollar:$195.96","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","110.76","52","","","Percent of Total Billed Charges","neg_dollar:$110.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","110.00","213.00",""
"OT EVAL MOD COMPLEX","97166","CPT","97000306","CDM","434","RC","","Facility","Outpatient","","","253","202.40","253.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","253.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","217.57","86","","","Percent of Total Billed Charges","neg_dollar:$217.57","177.10","70","","","Percent of Total Billed Charges","neg_dollar:$177.10","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","148.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$148.63;102% of Medicaid interim rate","189.75","75","","","Percent of Total Billed Charges","neg_dollar:$189.75","217.57","86","","","Percent of Total Billed Charges","neg_dollar:$217.57","177.10","70","","","Percent of Total Billed Charges","neg_dollar:$177.10","144.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$144.20;103.5% of Medicaid interim rate","253.00","150","","","Percent of Total Billed Charges","neg_dollar:$391.15;150% of Medicaid interim rate","202.40","80","","","Percent of Total Billed Charges","neg_dollar:$202.40;Percent of Total Billed Charges","232.76","92","","","Percent of Total Billed Charges","neg_dollar:$232.76","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","131.56","52","","","Percent of Total Billed Charges","neg_dollar:$131.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","131.00","253.00",""
"OT EVAL HIGH COMPLEX","97167","CPT","97000307","CDM","434","RC","","Facility","Outpatient","","","297","237.60","297.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","297.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","174.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$174.48;102% of Medicaid interim rate","222.75","75","","","Percent of Total Billed Charges","neg_dollar:$222.75","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","169.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$169.29;103.5% of Medicaid interim rate","297.00","150","","","Percent of Total Billed Charges","neg_dollar:$459.17;150% of Medicaid interim rate","237.60","80","","","Percent of Total Billed Charges","neg_dollar:$237.60;Percent of Total Billed Charges","273.24","92","","","Percent of Total Billed Charges","neg_dollar:$273.24","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","154.00","297.00",""
"OT RE-EVAL EST PLAN CARE","97168","CPT","97000308","CDM","434","RC","","Facility","Outpatient","","","170","136.00","170.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","170.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","146.20","86","","","Percent of Total Billed Charges","neg_dollar:$146.20","118.99","70","","","Percent of Total Billed Charges","neg_dollar:$118.99","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","99.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$99.87;102% of Medicaid interim rate","127.50","75","","","Percent of Total Billed Charges","neg_dollar:$127.50","146.20","86","","","Percent of Total Billed Charges","neg_dollar:$146.20","118.99","70","","","Percent of Total Billed Charges","neg_dollar:$118.99","96.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$96.89;103.5% of Medicaid interim rate","170.00","150","","","Percent of Total Billed Charges","neg_dollar:$262.82;150% of Medicaid interim rate","136.00","80","","","Percent of Total Billed Charges","neg_dollar:$136;Percent of Total Billed Charges","156.40","92","","","Percent of Total Billed Charges","neg_dollar:$156.40","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","88.40","52","","","Percent of Total Billed Charges","neg_dollar:$88.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","88.00","170.00",""
"THERAPEUTIC ACTIVITY DIR EA 15M","97530","CPT","97000033","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"SENSORY INTEGRATION EA 15M","97533","CPT","97000035","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"ADL/SELF CARE TRN EA 15M","97535","CPT","97000036","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"COMMUNITY/WORK TRAINING EA 15M","97537","CPT","97000037","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"WHEELCHAIR MNGMENT TRAINING EA 15M","97542","CPT","97000038","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"CAREGIVER TRAING 1ST 30 MIN","97550","CPT","90001469","CDM","942","RC","","Facility","Outpatient","","","186","148.80","186.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","96.72","52","","","Percent of Total Billed Charges","neg_dollar:$96.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","186.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","96.72","52","","","Percent of Total Billed Charges","neg_dollar:$96.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","96.72","52","","","Percent of Total Billed Charges","neg_dollar:$96.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","96.72","52","","","Percent of Total Billed Charges","neg_dollar:$96.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","159.96","86","","","Percent of Total Billed Charges","neg_dollar:$159.96","130.20","70","","","Percent of Total Billed Charges","neg_dollar:$130.20","96.72","52","","","Percent of Total Billed Charges","neg_dollar:$96.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","109.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$109.27;102% of Medicaid interim rate","139.50","75","","","Percent of Total Billed Charges","neg_dollar:$139.50","159.96","86","","","Percent of Total Billed Charges","neg_dollar:$159.96","130.20","70","","","Percent of Total Billed Charges","neg_dollar:$130.20","106.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$106.02;103.5% of Medicaid interim rate","186.00","150","","","Percent of Total Billed Charges","neg_dollar:$287.56;150% of Medicaid interim rate","148.80","80","","","Percent of Total Billed Charges","neg_dollar:$148.80;Percent of Total Billed Charges","171.12","92","","","Percent of Total Billed Charges","neg_dollar:$171.12","96.72","52","","","Percent of Total Billed Charges","neg_dollar:$96.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","96.72","52","","","Percent of Total Billed Charges","neg_dollar:$96.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","96.00","186.00",""
"CAREGIVER TRAING EA ADDL 15","97551","CPT","90001470","CDM","942","RC","","Facility","Outpatient","","","90","72.00","90.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","90.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.87;102% of Medicaid interim rate","67.50","75","","","Percent of Total Billed Charges","neg_dollar:$67.50","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","51.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.30;103.5% of Medicaid interim rate","90.00","150","","","Percent of Total Billed Charges","neg_dollar:$139.14;150% of Medicaid interim rate","72.00","80","","","Percent of Total Billed Charges","neg_dollar:$72;Percent of Total Billed Charges","82.80","92","","","Percent of Total Billed Charges","neg_dollar:$82.80","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.00","90.00",""
"GROUP CAREGIVER TRAINING","97552","CPT","90001471","CDM","942","RC","","Facility","Outpatient","","","74","59.20","74.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","38.48","52","","","Percent of Total Billed Charges","neg_dollar:$38.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","74.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","38.48","52","","","Percent of Total Billed Charges","neg_dollar:$38.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","38.48","52","","","Percent of Total Billed Charges","neg_dollar:$38.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","38.48","52","","","Percent of Total Billed Charges","neg_dollar:$38.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","63.64","86","","","Percent of Total Billed Charges","neg_dollar:$63.64","51.80","70","","","Percent of Total Billed Charges","neg_dollar:$51.80","38.48","52","","","Percent of Total Billed Charges","neg_dollar:$38.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","43.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$43.47;102% of Medicaid interim rate","55.50","75","","","Percent of Total Billed Charges","neg_dollar:$55.50","63.64","86","","","Percent of Total Billed Charges","neg_dollar:$63.64","51.80","70","","","Percent of Total Billed Charges","neg_dollar:$51.80","42.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$42.18;103.5% of Medicaid interim rate","74.00","150","","","Percent of Total Billed Charges","neg_dollar:$114.40;150% of Medicaid interim rate","59.20","80","","","Percent of Total Billed Charges","neg_dollar:$59.20;Percent of Total Billed Charges","68.08","92","","","Percent of Total Billed Charges","neg_dollar:$68.08","38.48","52","","","Percent of Total Billed Charges","neg_dollar:$38.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","38.48","52","","","Percent of Total Billed Charges","neg_dollar:$38.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","38.00","74.00",""
"SLCTV WND DEBRIDEM 20 CM OR <","97597","CPT","97000041","CDM","420","RC","","Facility","Outpatient","","","417","333.60","417.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","417.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","358.62","86","","","Percent of Total Billed Charges","neg_dollar:$358.62","291.90","70","","","Percent of Total Billed Charges","neg_dollar:$291.90","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","244.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$244.98;102% of Medicaid interim rate","312.75","75","","","Percent of Total Billed Charges","neg_dollar:$312.75","358.62","86","","","Percent of Total Billed Charges","neg_dollar:$358.62","291.90","70","","","Percent of Total Billed Charges","neg_dollar:$291.90","237.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.68;103.5% of Medicaid interim rate","417.00","150","","","Percent of Total Billed Charges","neg_dollar:$644.70;150% of Medicaid interim rate","333.60","80","","","Percent of Total Billed Charges","neg_dollar:$333.60;Percent of Total Billed Charges","383.64","92","","","Percent of Total Billed Charges","neg_dollar:$383.64","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","216.00","417.00",""
"SLCTV WND DEBRIDEM ADDTL 20 CM/<","97598","CPT","97000042","CDM","420","RC","","Facility","Outpatient","","","521","416.80","521.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","521.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","448.06","86","","","Percent of Total Billed Charges","neg_dollar:$448.06","364.70","70","","","Percent of Total Billed Charges","neg_dollar:$364.70","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","306.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$306.08;102% of Medicaid interim rate","390.75","75","","","Percent of Total Billed Charges","neg_dollar:$390.75","448.06","86","","","Percent of Total Billed Charges","neg_dollar:$448.06","364.70","70","","","Percent of Total Billed Charges","neg_dollar:$364.70","296.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$296.96;103.5% of Medicaid interim rate","521.00","150","","","Percent of Total Billed Charges","neg_dollar:$805.49;150% of Medicaid interim rate","416.80","80","","","Percent of Total Billed Charges","neg_dollar:$416.80;Percent of Total Billed Charges","479.32","92","","","Percent of Total Billed Charges","neg_dollar:$479.32","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","270.92","52","","","Percent of Total Billed Charges","neg_dollar:$270.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","270.00","521.00",""
"NSW DEBRIDEM WO A/SESSION","97602","CPT","97000043","CDM","430","RC","","Facility","Outpatient","","","417","333.60","417.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","417.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","358.62","86","","","Percent of Total Billed Charges","neg_dollar:$358.62","291.90","70","","","Percent of Total Billed Charges","neg_dollar:$291.90","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","244.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$244.98;102% of Medicaid interim rate","312.75","75","","","Percent of Total Billed Charges","neg_dollar:$312.75","358.62","86","","","Percent of Total Billed Charges","neg_dollar:$358.62","291.90","70","","","Percent of Total Billed Charges","neg_dollar:$291.90","237.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.68;103.5% of Medicaid interim rate","417.00","150","","","Percent of Total Billed Charges","neg_dollar:$644.70;150% of Medicaid interim rate","333.60","80","","","Percent of Total Billed Charges","neg_dollar:$333.60;Percent of Total Billed Charges","383.64","92","","","Percent of Total Billed Charges","neg_dollar:$383.64","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","216.84","52","","","Percent of Total Billed Charges","neg_dollar:$216.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","216.00","417.00",""
"NEG PRESS WOUND TX <=50 CM (DME)","97605","CPT","97000007","CDM","761","RC","","Facility","Outpatient","","","513","410.40","513.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","266.76","52","","","Percent of Total Billed Charges","neg_dollar:$266.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","513.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","266.76","52","","","Percent of Total Billed Charges","neg_dollar:$266.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","266.76","52","","","Percent of Total Billed Charges","neg_dollar:$266.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","266.76","52","","","Percent of Total Billed Charges","neg_dollar:$266.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","441.18","86","","","Percent of Total Billed Charges","neg_dollar:$441.18","359.09","70","","","Percent of Total Billed Charges","neg_dollar:$359.09","266.76","52","","","Percent of Total Billed Charges","neg_dollar:$266.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","301.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$301.38;102% of Medicaid interim rate","384.75","75","","","Percent of Total Billed Charges","neg_dollar:$384.75","441.18","86","","","Percent of Total Billed Charges","neg_dollar:$441.18","359.09","70","","","Percent of Total Billed Charges","neg_dollar:$359.09","292.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$292.40;103.5% of Medicaid interim rate","513.00","150","","","Percent of Total Billed Charges","neg_dollar:$793.12;150% of Medicaid interim rate","410.40","80","","","Percent of Total Billed Charges","neg_dollar:$410.40;Percent of Total Billed Charges","471.96","92","","","Percent of Total Billed Charges","neg_dollar:$471.96","266.76","52","","","Percent of Total Billed Charges","neg_dollar:$266.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","266.76","52","","","Percent of Total Billed Charges","neg_dollar:$266.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","266.00","513.00",""
"NEG PRESS WOUND TX >50 CM (DME)","97606","CPT","97000008","CDM","761","RC","","Facility","Outpatient","","","1046","836.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","543.92","52","","","Percent of Total Billed Charges","neg_dollar:$543.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","543.92","52","","","Percent of Total Billed Charges","neg_dollar:$543.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","543.92","52","","","Percent of Total Billed Charges","neg_dollar:$543.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","543.92","52","","","Percent of Total Billed Charges","neg_dollar:$543.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","899.56","86","","","Percent of Total Billed Charges","neg_dollar:$899.56","732.19","70","","","Percent of Total Billed Charges","neg_dollar:$732.19","543.92","52","","","Percent of Total Billed Charges","neg_dollar:$543.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","614.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$614.52;102% of Medicaid interim rate","784.50","75","","","Percent of Total Billed Charges","neg_dollar:$784.50","899.56","86","","","Percent of Total Billed Charges","neg_dollar:$899.56","732.19","70","","","Percent of Total Billed Charges","neg_dollar:$732.19","596.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$596.21;103.5% of Medicaid interim rate","1046.00","150","","","Percent of Total Billed Charges","neg_dollar:$1617.16;150% of Medicaid interim rate","836.80","80","","","Percent of Total Billed Charges","neg_dollar:$836.80;Percent of Total Billed Charges","962.32","92","","","Percent of Total Billed Charges","neg_dollar:$962.32","543.92","52","","","Percent of Total Billed Charges","neg_dollar:$543.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","543.92","52","","","Percent of Total Billed Charges","neg_dollar:$543.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","543.00","1046.00",""
"NEG PRESS WND TX <=50 SQ CM (NON-DME)","97607","CPT","97000282","CDM","761","RC","","Facility","Outpatient","","","841","672.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","437.32","52","","","Percent of Total Billed Charges","neg_dollar:$437.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","437.32","52","","","Percent of Total Billed Charges","neg_dollar:$437.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","437.32","52","","","Percent of Total Billed Charges","neg_dollar:$437.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","437.32","52","","","Percent of Total Billed Charges","neg_dollar:$437.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","723.26","86","","","Percent of Total Billed Charges","neg_dollar:$723.26","588.69","70","","","Percent of Total Billed Charges","neg_dollar:$588.69","437.32","52","","","Percent of Total Billed Charges","neg_dollar:$437.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","494.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$494.08;102% of Medicaid interim rate","630.75","75","","","Percent of Total Billed Charges","neg_dollar:$630.75","723.26","86","","","Percent of Total Billed Charges","neg_dollar:$723.26","588.69","70","","","Percent of Total Billed Charges","neg_dollar:$588.69","479.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$479.36;103.5% of Medicaid interim rate","841.00","150","","","Percent of Total Billed Charges","neg_dollar:$1300.22;150% of Medicaid interim rate","672.80","80","","","Percent of Total Billed Charges","neg_dollar:$672.80;Percent of Total Billed Charges","773.72","92","","","Percent of Total Billed Charges","neg_dollar:$773.72","437.32","52","","","Percent of Total Billed Charges","neg_dollar:$437.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","437.32","52","","","Percent of Total Billed Charges","neg_dollar:$437.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","437.00","841.00",""
"NEG PRESS WND TX >50 CM (NON-DME)","97608","CPT","97000283","CDM","761","RC","","Facility","Outpatient","","","1259","1007.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","739.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$739.66;102% of Medicaid interim rate","944.25","75","","","Percent of Total Billed Charges","neg_dollar:$944.25","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","717.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$717.62;103.5% of Medicaid interim rate","1259.00","150","","","Percent of Total Billed Charges","neg_dollar:$1946.47;150% of Medicaid interim rate","1007.20","80","","","Percent of Total Billed Charges","neg_dollar:$1007.20;Percent of Total Billed Charges","1158.28","92","","","Percent of Total Billed Charges","neg_dollar:$1158.28","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","654.68","52","","","Percent of Total Billed Charges","neg_dollar:$654.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","654.00","1259.00",""
"PHYSICAL PERFORM EA 15M","97750","CPT","97000044","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"ORTHOTIC MGMT AND TRAINING EA 15M","97760","CPT","97000045","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"PROSTHETIC TRAINING EA 15M","97761","CPT","97000046","CDM","420","RC","","Facility","Outpatient","","","121","96.80","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","121.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.08;102% of Medicaid interim rate","90.75","75","","","Percent of Total Billed Charges","neg_dollar:$90.75","104.06","86","","","Percent of Total Billed Charges","neg_dollar:$104.06","84.69","70","","","Percent of Total Billed Charges","neg_dollar:$84.69","68.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.97;103.5% of Medicaid interim rate","121.00","150","","","Percent of Total Billed Charges","neg_dollar:$187.07;150% of Medicaid interim rate","96.80","80","","","Percent of Total Billed Charges","neg_dollar:$96.80;Percent of Total Billed Charges","111.32","92","","","Percent of Total Billed Charges","neg_dollar:$111.32","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.92","52","","","Percent of Total Billed Charges","neg_dollar:$62.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","62.00","121.00",""
"ORTH/PROSTH MGMT SUBQ ENC 15M","97763","CPT","97000316","CDM","420","RC","","Facility","Outpatient","","","179","143.20","179.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","179.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","153.94","86","","","Percent of Total Billed Charges","neg_dollar:$153.94","125.30","70","","","Percent of Total Billed Charges","neg_dollar:$125.30","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","105.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$105.16;102% of Medicaid interim rate","134.25","75","","","Percent of Total Billed Charges","neg_dollar:$134.25","153.94","86","","","Percent of Total Billed Charges","neg_dollar:$153.94","125.30","70","","","Percent of Total Billed Charges","neg_dollar:$125.30","102.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$102.02;103.5% of Medicaid interim rate","179.00","150","","","Percent of Total Billed Charges","neg_dollar:$276.74;150% of Medicaid interim rate","143.20","80","","","Percent of Total Billed Charges","neg_dollar:$143.20;Percent of Total Billed Charges","164.68","92","","","Percent of Total Billed Charges","neg_dollar:$164.68","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","93.08","52","","","Percent of Total Billed Charges","neg_dollar:$93.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","93.00","179.00",""
"INIT NUTRITION THERAPY; EACH 15M","97802","CPT","90000237","CDM","942","RC","","Facility","Outpatient","","","63","50.40","63.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","63.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","54.18","86","","","Percent of Total Billed Charges","neg_dollar:$54.18","44.09","70","","","Percent of Total Billed Charges","neg_dollar:$44.09","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","37.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.01;102% of Medicaid interim rate","47.25","75","","","Percent of Total Billed Charges","neg_dollar:$47.25","54.18","86","","","Percent of Total Billed Charges","neg_dollar:$54.18","44.09","70","","","Percent of Total Billed Charges","neg_dollar:$44.09","35.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.91;103.5% of Medicaid interim rate","63.00","150","","","Percent of Total Billed Charges","neg_dollar:$97.40;150% of Medicaid interim rate","50.40","80","","","Percent of Total Billed Charges","neg_dollar:$50.40;Percent of Total Billed Charges","57.96","92","","","Percent of Total Billed Charges","neg_dollar:$57.96","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","32.00","63.00",""
"RE-ASSESS NUTRITION THER; EA 15M","97803","CPT","90000238","CDM","942","RC","","Facility","Outpatient","","","63","50.40","63.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","63.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","54.18","86","","","Percent of Total Billed Charges","neg_dollar:$54.18","44.09","70","","","Percent of Total Billed Charges","neg_dollar:$44.09","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","37.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.01;102% of Medicaid interim rate","47.25","75","","","Percent of Total Billed Charges","neg_dollar:$47.25","54.18","86","","","Percent of Total Billed Charges","neg_dollar:$54.18","44.09","70","","","Percent of Total Billed Charges","neg_dollar:$44.09","35.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.91;103.5% of Medicaid interim rate","63.00","150","","","Percent of Total Billed Charges","neg_dollar:$97.40;150% of Medicaid interim rate","50.40","80","","","Percent of Total Billed Charges","neg_dollar:$50.40;Percent of Total Billed Charges","57.96","92","","","Percent of Total Billed Charges","neg_dollar:$57.96","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","32.76","52","","","Percent of Total Billed Charges","neg_dollar:$32.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","32.00","63.00",""
"SPECIMEN HANDLING OFFICE-LAB","99000","CPT","80001130","CDM","300","RC","","Facility","Outpatient","","","47","37.60","47.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","24.44","52","","","Percent of Total Billed Charges","neg_dollar:$24.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","47.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","24.44","52","","","Percent of Total Billed Charges","neg_dollar:$24.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.44","52","","","Percent of Total Billed Charges","neg_dollar:$24.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.44","52","","","Percent of Total Billed Charges","neg_dollar:$24.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","40.42","86","","","Percent of Total Billed Charges","neg_dollar:$40.42","32.90","70","","","Percent of Total Billed Charges","neg_dollar:$32.90","24.44","52","","","Percent of Total Billed Charges","neg_dollar:$24.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","27.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.61;102% of Medicaid interim rate","35.25","75","","","Percent of Total Billed Charges","neg_dollar:$35.25","40.42","86","","","Percent of Total Billed Charges","neg_dollar:$40.42","32.90","70","","","Percent of Total Billed Charges","neg_dollar:$32.90","26.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.79;103.5% of Medicaid interim rate","47.00","150","","","Percent of Total Billed Charges","neg_dollar:$72.66;150% of Medicaid interim rate","37.60","80","","","Percent of Total Billed Charges","neg_dollar:$37.60;Percent of Total Billed Charges","","","","47.00","Fee Schedule","","24.44","52","","","Percent of Total Billed Charges","neg_dollar:$24.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","24.44","52","","","Percent of Total Billed Charges","neg_dollar:$24.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","24.00","47.00",""
"MOD SED SAME PHYS/QHP 5/>YRS 15M","99152","CPT","90001035","CDM","370","RC","","Facility","Outpatient","","","176","140.80","176.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","91.52","52","","","Percent of Total Billed Charges","neg_dollar:$91.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","176.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","91.52","52","","","Percent of Total Billed Charges","neg_dollar:$91.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","91.52","52","","","Percent of Total Billed Charges","neg_dollar:$91.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","91.52","52","","","Percent of Total Billed Charges","neg_dollar:$91.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","151.35","86","","","Percent of Total Billed Charges","neg_dollar:$151.35","123.19","70","","","Percent of Total Billed Charges","neg_dollar:$123.19","91.52","52","","","Percent of Total Billed Charges","neg_dollar:$91.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","103.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$103.39;102% of Medicaid interim rate","132.00","75","","","Percent of Total Billed Charges","neg_dollar:$132","151.35","86","","","Percent of Total Billed Charges","neg_dollar:$151.35","123.19","70","","","Percent of Total Billed Charges","neg_dollar:$123.19","100.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$100.32;103.5% of Medicaid interim rate","176.00","150","","","Percent of Total Billed Charges","neg_dollar:$272.10;150% of Medicaid interim rate","140.80","80","","","Percent of Total Billed Charges","neg_dollar:$140.80;Percent of Total Billed Charges","161.92","92","","","Percent of Total Billed Charges","neg_dollar:$161.92","91.52","52","","","Percent of Total Billed Charges","neg_dollar:$91.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","91.52","52","","","Percent of Total Billed Charges","neg_dollar:$91.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","91.00","176.00",""
"MOD SED SAME PHYS/QHP EA ADD 15M","99153","CPT","90001036","CDM","370","RC","","Facility","Outpatient","","","36","28.80","36.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","18.72","52","","","Percent of Total Billed Charges","neg_dollar:$18.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","36.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","18.72","52","","","Percent of Total Billed Charges","neg_dollar:$18.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.72","52","","","Percent of Total Billed Charges","neg_dollar:$18.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.72","52","","","Percent of Total Billed Charges","neg_dollar:$18.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.96","86","","","Percent of Total Billed Charges","neg_dollar:$30.96","25.20","70","","","Percent of Total Billed Charges","neg_dollar:$25.20","18.72","52","","","Percent of Total Billed Charges","neg_dollar:$18.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","21.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.14;102% of Medicaid interim rate","27.00","75","","","Percent of Total Billed Charges","neg_dollar:$27","30.96","86","","","Percent of Total Billed Charges","neg_dollar:$30.96","25.20","70","","","Percent of Total Billed Charges","neg_dollar:$25.20","20.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.52;103.5% of Medicaid interim rate","36.00","150","","","Percent of Total Billed Charges","neg_dollar:$55.65;150% of Medicaid interim rate","28.80","80","","","Percent of Total Billed Charges","neg_dollar:$28.80;Percent of Total Billed Charges","33.12","92","","","Percent of Total Billed Charges","neg_dollar:$33.12","18.72","52","","","Percent of Total Billed Charges","neg_dollar:$18.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","18.72","52","","","Percent of Total Billed Charges","neg_dollar:$18.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","18.00","36.00",""
"O/P VISIT NEW LEVEL 2","99202","CPT","99000002","CDM","510","RC","","Facility","Outpatient","","","317","253.60","317.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","164.84","52","","","Percent of Total Billed Charges","neg_dollar:$164.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","317.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","164.84","52","","","Percent of Total Billed Charges","neg_dollar:$164.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","164.84","52","","","Percent of Total Billed Charges","neg_dollar:$164.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","164.84","52","","","Percent of Total Billed Charges","neg_dollar:$164.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","272.62","86","","","Percent of Total Billed Charges","neg_dollar:$272.62","221.89","70","","","Percent of Total Billed Charges","neg_dollar:$221.89","164.84","52","","","Percent of Total Billed Charges","neg_dollar:$164.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","186.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$186.23;102% of Medicaid interim rate","237.75","75","","","Percent of Total Billed Charges","neg_dollar:$237.75","272.62","86","","","Percent of Total Billed Charges","neg_dollar:$272.62","221.89","70","","","Percent of Total Billed Charges","neg_dollar:$221.89","180.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$180.69;103.5% of Medicaid interim rate","317.00","150","","","Percent of Total Billed Charges","neg_dollar:$490.09;150% of Medicaid interim rate","253.60","80","","","Percent of Total Billed Charges","neg_dollar:$253.60;Percent of Total Billed Charges","291.64","92","","","Percent of Total Billed Charges","neg_dollar:$291.64","164.84","52","","","Percent of Total Billed Charges","neg_dollar:$164.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","164.84","52","","","Percent of Total Billed Charges","neg_dollar:$164.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","164.00","317.00",""
"O/P VISIT NEW LEVEL 3","99203","CPT","99000003","CDM","510","RC","","Facility","Outpatient","","","394","315.20","394.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","204.88","52","","","Percent of Total Billed Charges","neg_dollar:$204.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","394.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","204.88","52","","","Percent of Total Billed Charges","neg_dollar:$204.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","204.88","52","","","Percent of Total Billed Charges","neg_dollar:$204.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","204.88","52","","","Percent of Total Billed Charges","neg_dollar:$204.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","338.84","86","","","Percent of Total Billed Charges","neg_dollar:$338.84","275.79","70","","","Percent of Total Billed Charges","neg_dollar:$275.79","204.88","52","","","Percent of Total Billed Charges","neg_dollar:$204.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","231.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$231.47;102% of Medicaid interim rate","295.50","75","","","Percent of Total Billed Charges","neg_dollar:$295.50","338.84","86","","","Percent of Total Billed Charges","neg_dollar:$338.84","275.79","70","","","Percent of Total Billed Charges","neg_dollar:$275.79","224.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$224.57;103.5% of Medicaid interim rate","394.00","150","","","Percent of Total Billed Charges","neg_dollar:$609.14;150% of Medicaid interim rate","315.20","80","","","Percent of Total Billed Charges","neg_dollar:$315.20;Percent of Total Billed Charges","362.48","92","","","Percent of Total Billed Charges","neg_dollar:$362.48","204.88","52","","","Percent of Total Billed Charges","neg_dollar:$204.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","204.88","52","","","Percent of Total Billed Charges","neg_dollar:$204.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","204.00","394.00",""
"O/P VISIT EST LEVEL 1 (< 10 MIN)","99211","CPT","99000011","CDM","510","RC","","Facility","Outpatient","","","226","180.80","226.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","226.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","194.35","86","","","Percent of Total Billed Charges","neg_dollar:$194.35","158.20","70","","","Percent of Total Billed Charges","neg_dollar:$158.20","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","132.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$132.77;102% of Medicaid interim rate","169.50","75","","","Percent of Total Billed Charges","neg_dollar:$169.50","194.35","86","","","Percent of Total Billed Charges","neg_dollar:$194.35","158.20","70","","","Percent of Total Billed Charges","neg_dollar:$158.20","128.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$128.82;103.5% of Medicaid interim rate","226.00","150","","","Percent of Total Billed Charges","neg_dollar:$349.40;150% of Medicaid interim rate","180.80","80","","","Percent of Total Billed Charges","neg_dollar:$180.80;Percent of Total Billed Charges","207.92","92","","","Percent of Total Billed Charges","neg_dollar:$207.92","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","117.00","226.00",""
"O/P VISIT EST LEVEL 2 (10-19 MIN)","99212","CPT","99000012","CDM","510","RC","","Facility","Outpatient","","","312","249.60","312.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","312.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","268.32","86","","","Percent of Total Billed Charges","neg_dollar:$268.32","218.39","70","","","Percent of Total Billed Charges","neg_dollar:$218.39","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","183.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$183.29;102% of Medicaid interim rate","234.00","75","","","Percent of Total Billed Charges","neg_dollar:$234","268.32","86","","","Percent of Total Billed Charges","neg_dollar:$268.32","218.39","70","","","Percent of Total Billed Charges","neg_dollar:$218.39","177.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$177.83;103.5% of Medicaid interim rate","312.00","150","","","Percent of Total Billed Charges","neg_dollar:$482.36;150% of Medicaid interim rate","249.60","80","","","Percent of Total Billed Charges","neg_dollar:$249.60;Percent of Total Billed Charges","287.04","92","","","Percent of Total Billed Charges","neg_dollar:$287.04","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.24","52","","","Percent of Total Billed Charges","neg_dollar:$162.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","162.00","312.00",""
"O/P VISIT EST LEVEL 3 (20-29 MIN)","99213","CPT","99000013","CDM","510","RC","","Facility","Outpatient","","","387","309.60","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","387.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","227.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$227.36;102% of Medicaid interim rate","290.25","75","","","Percent of Total Billed Charges","neg_dollar:$290.25","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","220.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$220.58;103.5% of Medicaid interim rate","387.00","150","","","Percent of Total Billed Charges","neg_dollar:$598.32;150% of Medicaid interim rate","309.60","80","","","Percent of Total Billed Charges","neg_dollar:$309.60;Percent of Total Billed Charges","356.04","92","","","Percent of Total Billed Charges","neg_dollar:$356.04","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.24","52","","","Percent of Total Billed Charges","neg_dollar:$201.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","201.00","387.00",""
"O/P VISIT EST LEVEL 4 (30-39 MIN)","99214","CPT","99000014","CDM","510","RC","","Facility","Outpatient","","","458","366.40","458.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","238.16","52","","","Percent of Total Billed Charges","neg_dollar:$238.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","458.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","238.16","52","","","Percent of Total Billed Charges","neg_dollar:$238.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","238.16","52","","","Percent of Total Billed Charges","neg_dollar:$238.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","238.16","52","","","Percent of Total Billed Charges","neg_dollar:$238.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","393.88","86","","","Percent of Total Billed Charges","neg_dollar:$393.88","320.59","70","","","Percent of Total Billed Charges","neg_dollar:$320.59","238.16","52","","","Percent of Total Billed Charges","neg_dollar:$238.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","269.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$269.07;102% of Medicaid interim rate","343.50","75","","","Percent of Total Billed Charges","neg_dollar:$343.50","393.88","86","","","Percent of Total Billed Charges","neg_dollar:$393.88","320.59","70","","","Percent of Total Billed Charges","neg_dollar:$320.59","261.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$261.06;103.5% of Medicaid interim rate","458.00","150","","","Percent of Total Billed Charges","neg_dollar:$708.09;150% of Medicaid interim rate","366.40","80","","","Percent of Total Billed Charges","neg_dollar:$366.40;Percent of Total Billed Charges","421.36","92","","","Percent of Total Billed Charges","neg_dollar:$421.36","238.16","52","","","Percent of Total Billed Charges","neg_dollar:$238.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","238.16","52","","","Percent of Total Billed Charges","neg_dollar:$238.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","238.00","458.00",""
"ED LEVEL 1 VISIT","99281","CPT","99000016","CDM","450","RC","","Facility","Outpatient","","","226","180.80","226.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","226.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","194.35","86","","","Percent of Total Billed Charges","neg_dollar:$194.35","158.20","70","","","Percent of Total Billed Charges","neg_dollar:$158.20","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","132.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$132.77;102% of Medicaid interim rate","169.50","75","","","Percent of Total Billed Charges","neg_dollar:$169.50","194.35","86","","","Percent of Total Billed Charges","neg_dollar:$194.35","158.20","70","","","Percent of Total Billed Charges","neg_dollar:$158.20","128.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$128.82;103.5% of Medicaid interim rate","226.00","150","","","Percent of Total Billed Charges","neg_dollar:$349.40;150% of Medicaid interim rate","180.80","80","","","Percent of Total Billed Charges","neg_dollar:$180.80;Percent of Total Billed Charges","207.92","92","","","Percent of Total Billed Charges","neg_dollar:$207.92","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","117.52","52","","","Percent of Total Billed Charges","neg_dollar:$117.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","117.00","226.00",""
"ED LEVEL 1 INIT ASSESS","99281","CPT","99000017","CDM","450","RC","","Facility","Outpatient","","","33","26.40","33.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.38","86","","","Percent of Total Billed Charges","neg_dollar:$28.38","23.09","70","","","Percent of Total Billed Charges","neg_dollar:$23.09","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.38;102% of Medicaid interim rate","24.75","75","","","Percent of Total Billed Charges","neg_dollar:$24.75","28.38","86","","","Percent of Total Billed Charges","neg_dollar:$28.38","23.09","70","","","Percent of Total Billed Charges","neg_dollar:$23.09","18.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.81;103.5% of Medicaid interim rate","33.00","150","","","Percent of Total Billed Charges","neg_dollar:$51.01;150% of Medicaid interim rate","26.40","80","","","Percent of Total Billed Charges","neg_dollar:$26.40;Percent of Total Billed Charges","30.36","92","","","Percent of Total Billed Charges","neg_dollar:$30.36","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","33.00",""
"ED LEVEL 2 VISIT","99282","CPT","99000018","CDM","450","RC","","Facility","Outpatient","","","270","216.00","270.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","270.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","232.20","86","","","Percent of Total Billed Charges","neg_dollar:$232.20","189.00","70","","","Percent of Total Billed Charges","neg_dollar:$189","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","158.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$158.62;102% of Medicaid interim rate","202.50","75","","","Percent of Total Billed Charges","neg_dollar:$202.50","232.20","86","","","Percent of Total Billed Charges","neg_dollar:$232.20","189.00","70","","","Percent of Total Billed Charges","neg_dollar:$189","153.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$153.89;103.5% of Medicaid interim rate","270.00","150","","","Percent of Total Billed Charges","neg_dollar:$417.43;150% of Medicaid interim rate","216.00","80","","","Percent of Total Billed Charges","neg_dollar:$216;Percent of Total Billed Charges","248.40","92","","","Percent of Total Billed Charges","neg_dollar:$248.40","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","140.00","270.00",""
"ED LEVEL 2 INIT ASSESS","99282","CPT","99000019","CDM","450","RC","","Facility","Outpatient","","","33","26.40","33.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.38","86","","","Percent of Total Billed Charges","neg_dollar:$28.38","23.09","70","","","Percent of Total Billed Charges","neg_dollar:$23.09","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.38;102% of Medicaid interim rate","24.75","75","","","Percent of Total Billed Charges","neg_dollar:$24.75","28.38","86","","","Percent of Total Billed Charges","neg_dollar:$28.38","23.09","70","","","Percent of Total Billed Charges","neg_dollar:$23.09","18.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.81;103.5% of Medicaid interim rate","33.00","150","","","Percent of Total Billed Charges","neg_dollar:$51.01;150% of Medicaid interim rate","26.40","80","","","Percent of Total Billed Charges","neg_dollar:$26.40;Percent of Total Billed Charges","30.36","92","","","Percent of Total Billed Charges","neg_dollar:$30.36","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","33.00",""
"ED LEVEL 3 VISIT","99283","CPT","99000020","CDM","450","RC","","Facility","Outpatient","","","466","372.80","466.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","242.32","52","","","Percent of Total Billed Charges","neg_dollar:$242.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","466.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","242.32","52","","","Percent of Total Billed Charges","neg_dollar:$242.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","242.32","52","","","Percent of Total Billed Charges","neg_dollar:$242.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","242.32","52","","","Percent of Total Billed Charges","neg_dollar:$242.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","400.76","86","","","Percent of Total Billed Charges","neg_dollar:$400.76","326.20","70","","","Percent of Total Billed Charges","neg_dollar:$326.20","242.32","52","","","Percent of Total Billed Charges","neg_dollar:$242.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","273.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$273.77;102% of Medicaid interim rate","349.50","75","","","Percent of Total Billed Charges","neg_dollar:$349.50","400.76","86","","","Percent of Total Billed Charges","neg_dollar:$400.76","326.20","70","","","Percent of Total Billed Charges","neg_dollar:$326.20","265.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$265.62;103.5% of Medicaid interim rate","466.00","150","","","Percent of Total Billed Charges","neg_dollar:$720.45;150% of Medicaid interim rate","372.80","80","","","Percent of Total Billed Charges","neg_dollar:$372.80;Percent of Total Billed Charges","428.72","92","","","Percent of Total Billed Charges","neg_dollar:$428.72","242.32","52","","","Percent of Total Billed Charges","neg_dollar:$242.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","242.32","52","","","Percent of Total Billed Charges","neg_dollar:$242.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","242.00","466.00",""
"ED LEVEL 3 INIT ASSESS","99283","CPT","99000021","CDM","450","RC","","Facility","Outpatient","","","33","26.40","33.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.38","86","","","Percent of Total Billed Charges","neg_dollar:$28.38","23.09","70","","","Percent of Total Billed Charges","neg_dollar:$23.09","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.38;102% of Medicaid interim rate","24.75","75","","","Percent of Total Billed Charges","neg_dollar:$24.75","28.38","86","","","Percent of Total Billed Charges","neg_dollar:$28.38","23.09","70","","","Percent of Total Billed Charges","neg_dollar:$23.09","18.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.81;103.5% of Medicaid interim rate","33.00","150","","","Percent of Total Billed Charges","neg_dollar:$51.01;150% of Medicaid interim rate","26.40","80","","","Percent of Total Billed Charges","neg_dollar:$26.40;Percent of Total Billed Charges","30.36","92","","","Percent of Total Billed Charges","neg_dollar:$30.36","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","33.00",""
"ED LEVEL 4 VISIT","99284","CPT","99000022","CDM","450","RC","","Facility","Outpatient","","","776","620.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","776.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","667.36","86","","","Percent of Total Billed Charges","neg_dollar:$667.36","543.19","70","","","Percent of Total Billed Charges","neg_dollar:$543.19","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","455.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$455.89;102% of Medicaid interim rate","582.00","75","","","Percent of Total Billed Charges","neg_dollar:$582","667.36","86","","","Percent of Total Billed Charges","neg_dollar:$667.36","543.19","70","","","Percent of Total Billed Charges","neg_dollar:$543.19","442.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$442.31;103.5% of Medicaid interim rate","776.00","150","","","Percent of Total Billed Charges","neg_dollar:$1199.73;150% of Medicaid interim rate","620.80","80","","","Percent of Total Billed Charges","neg_dollar:$620.80;Percent of Total Billed Charges","713.92","92","","","Percent of Total Billed Charges","neg_dollar:$713.92","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","403.00","776.00",""
"ED LEVEL 4 INIT ASSESS","99284","CPT","99000023","CDM","450","RC","","Facility","Outpatient","","","33","26.40","33.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.38","86","","","Percent of Total Billed Charges","neg_dollar:$28.38","23.09","70","","","Percent of Total Billed Charges","neg_dollar:$23.09","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.38;102% of Medicaid interim rate","24.75","75","","","Percent of Total Billed Charges","neg_dollar:$24.75","28.38","86","","","Percent of Total Billed Charges","neg_dollar:$28.38","23.09","70","","","Percent of Total Billed Charges","neg_dollar:$23.09","18.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.81;103.5% of Medicaid interim rate","33.00","150","","","Percent of Total Billed Charges","neg_dollar:$51.01;150% of Medicaid interim rate","26.40","80","","","Percent of Total Billed Charges","neg_dollar:$26.40;Percent of Total Billed Charges","30.36","92","","","Percent of Total Billed Charges","neg_dollar:$30.36","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","33.00",""
"ED LEVEL 5 VISIT","99285","CPT","99000024","CDM","450","RC","","Facility","Outpatient","","","1127","901.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","969.22","86","","","Percent of Total Billed Charges","neg_dollar:$969.22","788.90","70","","","Percent of Total Billed Charges","neg_dollar:$788.90","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","662.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$662.11;102% of Medicaid interim rate","845.25","75","","","Percent of Total Billed Charges","neg_dollar:$845.25","969.22","86","","","Percent of Total Billed Charges","neg_dollar:$969.22","788.90","70","","","Percent of Total Billed Charges","neg_dollar:$788.90","642.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$642.39;103.5% of Medicaid interim rate","1127.00","150","","","Percent of Total Billed Charges","neg_dollar:$1742.39;150% of Medicaid interim rate","901.60","80","","","Percent of Total Billed Charges","neg_dollar:$901.60;Percent of Total Billed Charges","1036.84","92","","","Percent of Total Billed Charges","neg_dollar:$1036.84","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","586.00","1127.00",""
"ED LEVEL 5 INIT ASSESS","99285","CPT","99000038","CDM","450","RC","","Facility","Outpatient","","","33","26.40","33.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.38","86","","","Percent of Total Billed Charges","neg_dollar:$28.38","23.09","70","","","Percent of Total Billed Charges","neg_dollar:$23.09","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.38;102% of Medicaid interim rate","24.75","75","","","Percent of Total Billed Charges","neg_dollar:$24.75","28.38","86","","","Percent of Total Billed Charges","neg_dollar:$28.38","23.09","70","","","Percent of Total Billed Charges","neg_dollar:$23.09","18.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.81;103.5% of Medicaid interim rate","33.00","150","","","Percent of Total Billed Charges","neg_dollar:$51.01;150% of Medicaid interim rate","26.40","80","","","Percent of Total Billed Charges","neg_dollar:$26.40;Percent of Total Billed Charges","30.36","92","","","Percent of Total Billed Charges","neg_dollar:$30.36","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.16","52","","","Percent of Total Billed Charges","neg_dollar:$17.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","33.00",""
"CRITICAL CARE 30-74 MIN","99291","CPT","90000119","CDM","450","RC","","Facility","Outpatient","","","2534","2027.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1317.68","52","","","Percent of Total Billed Charges","neg_dollar:$1317.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1317.68","52","","","Percent of Total Billed Charges","neg_dollar:$1317.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1317.68","52","","","Percent of Total Billed Charges","neg_dollar:$1317.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1317.68","52","","","Percent of Total Billed Charges","neg_dollar:$1317.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","2179.24","86","","","Percent of Total Billed Charges","neg_dollar:$2179.24","1773.80","70","","","Percent of Total Billed Charges","neg_dollar:$1773.80","1317.68","52","","","Percent of Total Billed Charges","neg_dollar:$1317.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","1488.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$1488.72;102% of Medicaid interim rate","1900.50","75","","","Percent of Total Billed Charges","neg_dollar:$1900.50","2179.24","86","","","Percent of Total Billed Charges","neg_dollar:$2179.24","1773.80","70","","","Percent of Total Billed Charges","neg_dollar:$1773.80","1444.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$1444.37;103.5% of Medicaid interim rate","2534.00","150","","","Percent of Total Billed Charges","neg_dollar:$3917.69;150% of Medicaid interim rate","2027.20","80","","","Percent of Total Billed Charges","neg_dollar:$2027.20;Percent of Total Billed Charges","2331.28","92","","","Percent of Total Billed Charges","neg_dollar:$2331.28","1317.68","52","","","Percent of Total Billed Charges","neg_dollar:$1317.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","1317.68","52","","","Percent of Total Billed Charges","neg_dollar:$1317.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2534.00",""
"CRITICAL CARE EACH ADDTL 30 MIN","99292","CPT","90000120","CDM","450","RC","","Facility","Outpatient","","","608","486.40","608.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","608.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","522.88","86","","","Percent of Total Billed Charges","neg_dollar:$522.88","425.59","70","","","Percent of Total Billed Charges","neg_dollar:$425.59","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","357.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$357.19;102% of Medicaid interim rate","456.00","75","","","Percent of Total Billed Charges","neg_dollar:$456","522.88","86","","","Percent of Total Billed Charges","neg_dollar:$522.88","425.59","70","","","Percent of Total Billed Charges","neg_dollar:$425.59","346.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$346.55;103.5% of Medicaid interim rate","608.00","150","","","Percent of Total Billed Charges","neg_dollar:$939.99;150% of Medicaid interim rate","486.40","80","","","Percent of Total Billed Charges","neg_dollar:$486.40;Percent of Total Billed Charges","559.36","92","","","Percent of Total Billed Charges","neg_dollar:$559.36","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","316.16","52","","","Percent of Total Billed Charges","neg_dollar:$316.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","316.00","608.00",""
"SMOKE/TOBACCO COUNSELING 3-10 MIN","99406","CPT","90000121","CDM","942","RC","","Facility","Outpatient","","","79","63.20","79.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","79.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","67.94","86","","","Percent of Total Billed Charges","neg_dollar:$67.94","55.30","70","","","Percent of Total Billed Charges","neg_dollar:$55.30","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","46.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$46.41;102% of Medicaid interim rate","59.25","75","","","Percent of Total Billed Charges","neg_dollar:$59.25","67.94","86","","","Percent of Total Billed Charges","neg_dollar:$67.94","55.30","70","","","Percent of Total Billed Charges","neg_dollar:$55.30","45.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$45.02;103.5% of Medicaid interim rate","79.00","150","","","Percent of Total Billed Charges","neg_dollar:$122.13;150% of Medicaid interim rate","63.20","80","","","Percent of Total Billed Charges","neg_dollar:$63.20;Percent of Total Billed Charges","72.68","92","","","Percent of Total Billed Charges","neg_dollar:$72.68","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","41.00","79.00",""
"SMOKE/TOBACCO COUNSELING > 10 MIN","99407","CPT","90000122","CDM","942","RC","","Facility","Outpatient","","","149","119.20","149.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","77.48","52","","","Percent of Total Billed Charges","neg_dollar:$77.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","149.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","77.48","52","","","Percent of Total Billed Charges","neg_dollar:$77.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","77.48","52","","","Percent of Total Billed Charges","neg_dollar:$77.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","77.48","52","","","Percent of Total Billed Charges","neg_dollar:$77.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","128.14","86","","","Percent of Total Billed Charges","neg_dollar:$128.14","104.30","70","","","Percent of Total Billed Charges","neg_dollar:$104.30","77.48","52","","","Percent of Total Billed Charges","neg_dollar:$77.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","87.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$87.53;102% of Medicaid interim rate","111.75","75","","","Percent of Total Billed Charges","neg_dollar:$111.75","128.14","86","","","Percent of Total Billed Charges","neg_dollar:$128.14","104.30","70","","","Percent of Total Billed Charges","neg_dollar:$104.30","84.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$84.92;103.5% of Medicaid interim rate","149.00","150","","","Percent of Total Billed Charges","neg_dollar:$230.36;150% of Medicaid interim rate","119.20","80","","","Percent of Total Billed Charges","neg_dollar:$119.20;Percent of Total Billed Charges","137.08","92","","","Percent of Total Billed Charges","neg_dollar:$137.08","77.48","52","","","Percent of Total Billed Charges","neg_dollar:$77.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","77.48","52","","","Percent of Total Billed Charges","neg_dollar:$77.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","77.00","149.00",""
"GROUND MILEAGE PER STATUTE/MILE","A0425","HCPCS","80080001","CDM","540","RC","","Facility","Outpatient","","","29","23.20","29.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","15.08","52","","","Percent of Total Billed Charges","neg_dollar:$15.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","29.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","15.08","52","","","Percent of Total Billed Charges","neg_dollar:$15.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.08","52","","","Percent of Total Billed Charges","neg_dollar:$15.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.08","52","","","Percent of Total Billed Charges","neg_dollar:$15.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.94","86","","","Percent of Total Billed Charges","neg_dollar:$24.94","20.29","70","","","Percent of Total Billed Charges","neg_dollar:$20.29","15.08","52","","","Percent of Total Billed Charges","neg_dollar:$15.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","17.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.03;102% of Medicaid interim rate","21.75","75","","","Percent of Total Billed Charges","neg_dollar:$21.75","24.94","86","","","Percent of Total Billed Charges","neg_dollar:$24.94","20.29","70","","","Percent of Total Billed Charges","neg_dollar:$20.29","16.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.52;103.5% of Medicaid interim rate","29.00","150","","","Percent of Total Billed Charges","neg_dollar:$44.83;150% of Medicaid interim rate","23.20","80","","","Percent of Total Billed Charges","neg_dollar:$23.20;Percent of Total Billed Charges","26.68","92","","","Percent of Total Billed Charges","neg_dollar:$26.68","15.08","52","","","Percent of Total Billed Charges","neg_dollar:$15.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.08","52","","","Percent of Total Billed Charges","neg_dollar:$15.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.00","29.00",""
"ALS 1","A0426","HCPCS","80080002","CDM","540","RC","","Facility","Outpatient","","","846","676.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","727.56","86","","","Percent of Total Billed Charges","neg_dollar:$727.56","592.19","70","","","Percent of Total Billed Charges","neg_dollar:$592.19","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","497.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$497.02;102% of Medicaid interim rate","634.50","75","","","Percent of Total Billed Charges","neg_dollar:$634.50","727.56","86","","","Percent of Total Billed Charges","neg_dollar:$727.56","592.19","70","","","Percent of Total Billed Charges","neg_dollar:$592.19","482.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$482.21;103.5% of Medicaid interim rate","846.00","150","","","Percent of Total Billed Charges","neg_dollar:$1307.95;150% of Medicaid interim rate","676.80","80","","","Percent of Total Billed Charges","neg_dollar:$676.80;Percent of Total Billed Charges","778.32","92","","","Percent of Total Billed Charges","neg_dollar:$778.32","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","439.92","52","","","Percent of Total Billed Charges","neg_dollar:$439.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","439.00","846.00",""
"ALS 1 EMERGENT","A0427","HCPCS","80080003","CDM","540","RC","","Facility","Outpatient","","","1338","1070.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1150.68","86","","","Percent of Total Billed Charges","neg_dollar:$1150.68","936.59","70","","","Percent of Total Billed Charges","neg_dollar:$936.59","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","786.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$786.07;102% of Medicaid interim rate","1003.50","75","","","Percent of Total Billed Charges","neg_dollar:$1003.50","1150.68","86","","","Percent of Total Billed Charges","neg_dollar:$1150.68","936.59","70","","","Percent of Total Billed Charges","neg_dollar:$936.59","762.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$762.66;103.5% of Medicaid interim rate","1338.00","150","","","Percent of Total Billed Charges","neg_dollar:$2068.61;150% of Medicaid interim rate","1070.40","80","","","Percent of Total Billed Charges","neg_dollar:$1070.40;Percent of Total Billed Charges","1230.96","92","","","Percent of Total Billed Charges","neg_dollar:$1230.96","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","695.76","52","","","Percent of Total Billed Charges","neg_dollar:$695.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","695.00","1338.00",""
"BLS NON EMERGENT","A0428","HCPCS","80080004","CDM","540","RC","","Facility","Outpatient","","","705","564.00","705.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","705.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","606.30","86","","","Percent of Total Billed Charges","neg_dollar:$606.30","493.49","70","","","Percent of Total Billed Charges","neg_dollar:$493.49","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","414.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$414.18;102% of Medicaid interim rate","528.75","75","","","Percent of Total Billed Charges","neg_dollar:$528.75","606.30","86","","","Percent of Total Billed Charges","neg_dollar:$606.30","493.49","70","","","Percent of Total Billed Charges","neg_dollar:$493.49","401.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$401.84;103.5% of Medicaid interim rate","705.00","150","","","Percent of Total Billed Charges","neg_dollar:$1089.96;150% of Medicaid interim rate","564.00","80","","","Percent of Total Billed Charges","neg_dollar:$564;Percent of Total Billed Charges","648.60","92","","","Percent of Total Billed Charges","neg_dollar:$648.60","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.00","705.00",""
"MILEAGE AMB DISPATCH/DOA B4 TRANSPORT","A0428","HCPCS","80080019","CDM","540","RC","QL","Facility","Outpatient","","","2","1.60","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"BLS EMERGENCY","A0429","HCPCS","80080005","CDM","540","RC","","Facility","Outpatient","","","1127","901.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","969.22","86","","","Percent of Total Billed Charges","neg_dollar:$969.22","788.90","70","","","Percent of Total Billed Charges","neg_dollar:$788.90","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","662.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$662.11;102% of Medicaid interim rate","845.25","75","","","Percent of Total Billed Charges","neg_dollar:$845.25","969.22","86","","","Percent of Total Billed Charges","neg_dollar:$969.22","788.90","70","","","Percent of Total Billed Charges","neg_dollar:$788.90","642.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$642.39;103.5% of Medicaid interim rate","1127.00","150","","","Percent of Total Billed Charges","neg_dollar:$1742.39;150% of Medicaid interim rate","901.60","80","","","Percent of Total Billed Charges","neg_dollar:$901.60;Percent of Total Billed Charges","1036.84","92","","","Percent of Total Billed Charges","neg_dollar:$1036.84","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","586.04","52","","","Percent of Total Billed Charges","neg_dollar:$586.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","586.00","1127.00",""
"ALS 2","A0433","HCPCS","80080006","CDM","540","RC","","Facility","Outpatient","","","1829","1463.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","1572.94","86","","","Percent of Total Billed Charges","neg_dollar:$1572.94","1280.30","70","","","Percent of Total Billed Charges","neg_dollar:$1280.30","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","1074.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1074.53;102% of Medicaid interim rate","1371.75","75","","","Percent of Total Billed Charges","neg_dollar:$1371.75","1572.94","86","","","Percent of Total Billed Charges","neg_dollar:$1572.94","1280.30","70","","","Percent of Total Billed Charges","neg_dollar:$1280.30","1042.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1042.53;103.5% of Medicaid interim rate","1829.00","150","","","Percent of Total Billed Charges","neg_dollar:$2827.72;150% of Medicaid interim rate","1463.20","80","","","Percent of Total Billed Charges","neg_dollar:$1463.20;Percent of Total Billed Charges","1682.68","92","","","Percent of Total Billed Charges","neg_dollar:$1682.68","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1829.00",""
"SPECIALTY CARE TRANSPORT","A0434","HCPCS","80080007","CDM","540","RC","","Facility","Outpatient","","","2393","1914.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1244.36","52","","","Percent of Total Billed Charges","neg_dollar:$1244.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1244.36","52","","","Percent of Total Billed Charges","neg_dollar:$1244.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1244.36","52","","","Percent of Total Billed Charges","neg_dollar:$1244.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","1244.36","52","","","Percent of Total Billed Charges","neg_dollar:$1244.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","2057.98","86","","","Percent of Total Billed Charges","neg_dollar:$2057.98","1675.10","70","","","Percent of Total Billed Charges","neg_dollar:$1675.10","1244.36","52","","","Percent of Total Billed Charges","neg_dollar:$1244.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","1405.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$1405.88;102% of Medicaid interim rate","1794.75","75","","","Percent of Total Billed Charges","neg_dollar:$1794.75","2057.98","86","","","Percent of Total Billed Charges","neg_dollar:$2057.98","1675.10","70","","","Percent of Total Billed Charges","neg_dollar:$1675.10","1364.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$1364.01;103.5% of Medicaid interim rate","2393.00","150","","","Percent of Total Billed Charges","neg_dollar:$3699.69;150% of Medicaid interim rate","1914.40","80","","","Percent of Total Billed Charges","neg_dollar:$1914.40;Percent of Total Billed Charges","2201.56","92","","","Percent of Total Billed Charges","neg_dollar:$2201.56","1244.36","52","","","Percent of Total Billed Charges","neg_dollar:$1244.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","1244.36","52","","","Percent of Total Billed Charges","neg_dollar:$1244.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2393.00",""
"ALGINATE/FG DRESS 16 SQIN/<EA TAKE HOME","A6196","HCPCS","27002557","CDM","623","RC","","Facility","Outpatient","","","137","109.60","137.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","71.24","52","","","Percent of Total Billed Charges","neg_dollar:$71.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","137.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","71.24","52","","","Percent of Total Billed Charges","neg_dollar:$71.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","71.24","52","","","Percent of Total Billed Charges","neg_dollar:$71.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","71.24","52","","","Percent of Total Billed Charges","neg_dollar:$71.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","117.82","86","","","Percent of Total Billed Charges","neg_dollar:$117.82","95.89","70","","","Percent of Total Billed Charges","neg_dollar:$95.89","71.24","52","","","Percent of Total Billed Charges","neg_dollar:$71.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","80.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$80.48;102% of Medicaid interim rate","102.75","75","","","Percent of Total Billed Charges","neg_dollar:$102.75","117.82","86","","","Percent of Total Billed Charges","neg_dollar:$117.82","95.89","70","","","Percent of Total Billed Charges","neg_dollar:$95.89","78.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$78.08;103.5% of Medicaid interim rate","137.00","150","","","Percent of Total Billed Charges","neg_dollar:$211.80;150% of Medicaid interim rate","109.60","80","","","Percent of Total Billed Charges","neg_dollar:$109.60;Percent of Total Billed Charges","126.04","92","","","Percent of Total Billed Charges","neg_dollar:$126.04","71.24","52","","","Percent of Total Billed Charges","neg_dollar:$71.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","71.24","52","","","Percent of Total Billed Charges","neg_dollar:$71.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","71.00","137.00",""
"CLONIDINE HCL 0.1 MG PO TABS","A9270","HCPCS","60687-113-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"CLONIDINE HCL 0.1 MG PO TABS","A9270","HCPCS","60687-113-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.16","1.16","","","","1.16","Fee Schedule","","","","","1.16","Fee Schedule","101% of Medicare Fee Schedule","","","","1.16","Fee Schedule","","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","86","","","Percent of Total Billed Charges","neg_dollar:$1","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% of Medicaid interim rate","0.87","75","","","Percent of Total Billed Charges","neg_dollar:$0.87","1.00","86","","","Percent of Total Billed Charges","neg_dollar:$1","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.66;103.5% of Medicaid interim rate","1.16","150","","","Percent of Total Billed Charges","neg_dollar:$1.80;150% of Medicaid interim rate","0.93","80","","","Percent of Total Billed Charges","neg_dollar:$0.93;Percent of Total Billed Charges","1.07","92","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DIGOXIN 125 MCG PO TABS","A9270","HCPCS","00904-5921-61","NDC","250","RC","","Facility","Outpatient","1","ME","2.65","2.65","","","","2.65","Fee Schedule","","","","","2.65","Fee Schedule","","","","","2.65","Fee Schedule","","","52","","2.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.27","86","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","70","","","Percent of Total Billed Charges","neg_dollar:$1.85","","52","","2.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.55;102% of Medicaid interim rate","1.98","75","","","Percent of Total Billed Charges","neg_dollar:$1.98","2.27","86","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","70","","","Percent of Total Billed Charges","neg_dollar:$1.85","1.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.51;103.5% of Medicaid interim rate","2.65","150","","","Percent of Total Billed Charges","neg_dollar:$4.09;150% of Medicaid interim rate","2.12","80","","","Percent of Total Billed Charges","neg_dollar:$2.12;Percent of Total Billed Charges","2.43","92","","","Percent of Total Billed Charges","neg_dollar:$2.43","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.65","Fee Schedule","","1.00","2.00",""
"DIGOXIN 125 MCG PO TABS","A9270","HCPCS","00904-5921-61","NDC","637","RC","","Facility","Outpatient","1","ME","2.65","2.65","","","","2.65","Fee Schedule","","","","","2.65","Fee Schedule","101% of Medicare Fee Schedule","","","","2.65","Fee Schedule","","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.27","86","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","70","","","Percent of Total Billed Charges","neg_dollar:$1.85","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.55;102% of Medicaid interim rate","1.98","75","","","Percent of Total Billed Charges","neg_dollar:$1.98","2.27","86","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","70","","","Percent of Total Billed Charges","neg_dollar:$1.85","1.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.51;103.5% of Medicaid interim rate","2.65","150","","","Percent of Total Billed Charges","neg_dollar:$4.09;150% of Medicaid interim rate","2.12","80","","","Percent of Total Billed Charges","neg_dollar:$2.12;Percent of Total Billed Charges","2.43","92","","","Percent of Total Billed Charges","neg_dollar:$2.43","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"ROPINIROLE HCL 0.25 MG PO TABS","A9270","HCPCS","00904-6373-61","NDC","250","RC","","Facility","Outpatient","1","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"CALCITRIOL 0.25 MCG PO CAPS","A9270","HCPCS","60687-345-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.90","1.90","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","52","","1.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","","52","","1.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% of Medicaid interim rate","1.42","75","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;103.5% of Medicaid interim rate","1.90","150","","","Percent of Total Billed Charges","neg_dollar:$2.93;150% of Medicaid interim rate","1.52","80","","","Percent of Total Billed Charges","neg_dollar:$1.52;Percent of Total Billed Charges","1.74","92","","","Percent of Total Billed Charges","neg_dollar:$1.74","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.90","Fee Schedule","","1.00","1.00",""
"CALCITRIOL 0.25 MCG PO CAPS","A9270","HCPCS","60687-345-11","NDC","637","RC","","Facility","Outpatient","1","EA","1.90","1.90","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","101% of Medicare Fee Schedule","","","","1.90","Fee Schedule","","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% of Medicaid interim rate","1.42","75","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;103.5% of Medicaid interim rate","1.90","150","","","Percent of Total Billed Charges","neg_dollar:$2.93;150% of Medicaid interim rate","1.52","80","","","Percent of Total Billed Charges","neg_dollar:$1.52;Percent of Total Billed Charges","1.74","92","","","Percent of Total Billed Charges","neg_dollar:$1.74","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ROPINIROLE HCL 0.25 MG PO TABS","A9270","HCPCS","00904-6373-61","NDC","637","RC","","Facility","Outpatient","1","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TAMSULOSIN HCL 0.4 MG PO CAPS","A9270","HCPCS","68084-299-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.71","1.71","","","","1.71","Fee Schedule","","","","","1.71","Fee Schedule","","","","","1.71","Fee Schedule","","","52","","1.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.47","86","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","","52","","1.71","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$1;102% of Medicaid interim rate","1.28","75","","","Percent of Total Billed Charges","neg_dollar:$1.28","1.47","86","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.97;103.5% of Medicaid interim rate","1.71","150","","","Percent of Total Billed Charges","neg_dollar:$2.64;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.57","92","","","Percent of Total Billed Charges","neg_dollar:$1.57","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.71","Fee Schedule","","1.00","1.00",""
"NITROGLYCERIN 0.4 MG SL SUBL","A9270","HCPCS","59762-3304-3","NDC","637","RC","","Facility","Outpatient","1","ME","10.95","10.95","","","","10.95","Fee Schedule","","","","","10.95","Fee Schedule","101% of Medicare Fee Schedule","","","","10.95","Fee Schedule","","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.41","86","","","Percent of Total Billed Charges","neg_dollar:$9.41","7.66","70","","","Percent of Total Billed Charges","neg_dollar:$7.66","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.43;102% of Medicaid interim rate","8.21","75","","","Percent of Total Billed Charges","neg_dollar:$8.21","9.41","86","","","Percent of Total Billed Charges","neg_dollar:$9.41","7.66","70","","","Percent of Total Billed Charges","neg_dollar:$7.66","6.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.24;103.5% of Medicaid interim rate","10.95","150","","","Percent of Total Billed Charges","neg_dollar:$16.92;150% of Medicaid interim rate","8.76","80","","","Percent of Total Billed Charges","neg_dollar:$8.76;Percent of Total Billed Charges","10.07","92","","","Percent of Total Billed Charges","neg_dollar:$10.07","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"NITROGLYCERIN 0.4 MG SL SUBL","A9270","HCPCS","68462-639-25","NDC","250","RC","","Facility","Outpatient","1","ME","13.40","13.40","","","","13.40","Fee Schedule","","","","","13.40","Fee Schedule","","","","","13.40","Fee Schedule","","","52","","13.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.52","86","","","Percent of Total Billed Charges","neg_dollar:$11.52","9.37","70","","","Percent of Total Billed Charges","neg_dollar:$9.37","","52","","13.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.87;102% of Medicaid interim rate","10.05","75","","","Percent of Total Billed Charges","neg_dollar:$10.05","11.52","86","","","Percent of Total Billed Charges","neg_dollar:$11.52","9.37","70","","","Percent of Total Billed Charges","neg_dollar:$9.37","7.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.63;103.5% of Medicaid interim rate","13.40","150","","","Percent of Total Billed Charges","neg_dollar:$20.71;150% of Medicaid interim rate","10.72","80","","","Percent of Total Billed Charges","neg_dollar:$10.72;Percent of Total Billed Charges","12.32","92","","","Percent of Total Billed Charges","neg_dollar:$12.32","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","13.40","Fee Schedule","","6.00","13.00",""
"TAMSULOSIN HCL 0.4 MG PO CAPS","A9270","HCPCS","68084-299-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.64","1.64","","","","1.64","Fee Schedule","","","","","1.64","Fee Schedule","101% of Medicare Fee Schedule","","","","1.64","Fee Schedule","","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.23","75","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.64","150","","","Percent of Total Billed Charges","neg_dollar:$2.54;150% of Medicaid interim rate","1.31","80","","","Percent of Total Billed Charges","neg_dollar:$1.31;Percent of Total Billed Charges","1.51","92","","","Percent of Total Billed Charges","neg_dollar:$1.51","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"NITROGLYCERIN 0.4 MG SL SUBL","A9270","HCPCS","68462-639-25","NDC","637","RC","","Facility","Outpatient","1","ME","13.40","13.40","","","","13.40","Fee Schedule","","","","","13.40","Fee Schedule","101% of Medicare Fee Schedule","","","","13.40","Fee Schedule","","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.52","86","","","Percent of Total Billed Charges","neg_dollar:$11.52","9.37","70","","","Percent of Total Billed Charges","neg_dollar:$9.37","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.87;102% of Medicaid interim rate","10.05","75","","","Percent of Total Billed Charges","neg_dollar:$10.05","11.52","86","","","Percent of Total Billed Charges","neg_dollar:$11.52","9.37","70","","","Percent of Total Billed Charges","neg_dollar:$9.37","7.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.63;103.5% of Medicaid interim rate","13.40","150","","","Percent of Total Billed Charges","neg_dollar:$20.71;150% of Medicaid interim rate","10.72","80","","","Percent of Total Billed Charges","neg_dollar:$10.72;Percent of Total Billed Charges","12.32","92","","","Percent of Total Billed Charges","neg_dollar:$12.32","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","13.00",""
"NITROGLYCERIN 0.4 MG SL SUBL","A9270","HCPCS","68462-639-45","NDC","637","RC","","Facility","Outpatient","1","ME","10.65","10.65","","","","10.65","Fee Schedule","","","","","10.65","Fee Schedule","101% of Medicare Fee Schedule","","","","10.65","Fee Schedule","","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.15","86","","","Percent of Total Billed Charges","neg_dollar:$9.15","7.45","70","","","Percent of Total Billed Charges","neg_dollar:$7.45","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.25;102% of Medicaid interim rate","7.98","75","","","Percent of Total Billed Charges","neg_dollar:$7.98","9.15","86","","","Percent of Total Billed Charges","neg_dollar:$9.15","7.45","70","","","Percent of Total Billed Charges","neg_dollar:$7.45","6.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.07;103.5% of Medicaid interim rate","10.65","150","","","Percent of Total Billed Charges","neg_dollar:$16.46;150% of Medicaid interim rate","8.52","80","","","Percent of Total Billed Charges","neg_dollar:$8.52;Percent of Total Billed Charges","9.79","92","","","Percent of Total Billed Charges","neg_dollar:$9.79","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"ANAGRELIDE HCL 0.5 MG PO CAPS","A9270","HCPCS","00172-5241-60","NDC","250","RC","","Facility","Outpatient","1","ME","2","2.00","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","","52","","2.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.00","Fee Schedule","","1.00","2.00",""
"PRAMIPEXOLE DIHYDROCHLORIDE 0.5 MG PO TABS","A9270","HCPCS","60687-581-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.53","1.53","","","","1.53","Fee Schedule","","","","","1.53","Fee Schedule","","","","","1.53","Fee Schedule","","","52","","1.53","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","86","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.07","70","","","Percent of Total Billed Charges","neg_dollar:$1.07","","52","","1.53","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.90;102% of Medicaid interim rate","1.15","75","","","Percent of Total Billed Charges","neg_dollar:$1.15","1.32","86","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.07","70","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.87;103.5% of Medicaid interim rate","1.53","150","","","Percent of Total Billed Charges","neg_dollar:$2.37;150% of Medicaid interim rate","1.22","80","","","Percent of Total Billed Charges","neg_dollar:$1.22;Percent of Total Billed Charges","1.41","92","","","Percent of Total Billed Charges","neg_dollar:$1.41","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.53","Fee Schedule","","1.00","1.00",""
"LORAZEPAM 0.5 MG PO TABS","A9270","HCPCS","69315-904-01","NDC","250","RC","","Facility","Outpatient","1","ME","0.81","0.81","","","","0.81","Fee Schedule","","","","","0.81","Fee Schedule","","","","","0.81","Fee Schedule","","","52","","0.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","86","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","","52","","0.81","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% of Medicaid interim rate","0.61","75","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.70","86","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;103.5% of Medicaid interim rate","0.81","150","","","Percent of Total Billed Charges","neg_dollar:$1.26;150% of Medicaid interim rate","0.65","80","","","Percent of Total Billed Charges","neg_dollar:$0.65;Percent of Total Billed Charges","0.75","92","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.81","Fee Schedule","","1.00","1.00",""
"ALPRAZOLAM 0.5 MG PO TABS","A9270","HCPCS","59762-3720-1","NDC","250","RC","","Facility","Outpatient","1","ME","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","","52","","0.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% of Medicaid interim rate","0.63","75","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.31;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.85","Fee Schedule","","1.00","1.00",""
"CLONAZEPAM 0.5 MG PO TABS","A9270","HCPCS","60687-861-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.31","1.31","","","","1.31","Fee Schedule","","","","","1.31","Fee Schedule","","","","","1.31","Fee Schedule","","","52","","1.31","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.13","86","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","70","","","Percent of Total Billed Charges","neg_dollar:$0.92","","52","","1.31","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% of Medicaid interim rate","0.98","75","","","Percent of Total Billed Charges","neg_dollar:$0.98","1.13","86","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","70","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.75;103.5% of Medicaid interim rate","1.31","150","","","Percent of Total Billed Charges","neg_dollar:$2.03;150% of Medicaid interim rate","1.05","80","","","Percent of Total Billed Charges","neg_dollar:$1.05;Percent of Total Billed Charges","1.21","92","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.31","Fee Schedule","","1.00","1.00",""
"CLONAZEPAM 0.5 MG PO TABS","A9270","HCPCS","60687-544-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.12","86","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.91","70","","","Percent of Total Billed Charges","neg_dollar:$0.91","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.98","75","","","Percent of Total Billed Charges","neg_dollar:$0.98","1.12","86","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.91","70","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2.02;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.20","92","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"LORAZEPAM 0.5 MG PO TABS","A9270","HCPCS","60687-627-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.14","1.14","","","","1.14","Fee Schedule","","","","","1.14","Fee Schedule","","","","","1.14","Fee Schedule","","","52","","1.14","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","","52","","1.14","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.14","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.14","Fee Schedule","","1.00","1.00",""
"LORAZEPAM 0.5 MG PO TABS","A9270","HCPCS","60687-627-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.26","1.26","","","","1.26","Fee Schedule","","","","","1.26","Fee Schedule","101% of Medicare Fee Schedule","","","","1.26","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","86","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","70","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;102% of Medicaid interim rate","0.94","75","","","Percent of Total Billed Charges","neg_dollar:$0.94","1.08","86","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","70","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.72;103.5% of Medicaid interim rate","1.26","150","","","Percent of Total Billed Charges","neg_dollar:$1.95;150% of Medicaid interim rate","1.01","80","","","Percent of Total Billed Charges","neg_dollar:$1.01;Percent of Total Billed Charges","1.16","92","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ALPRAZOLAM 0.5 MG PO TABS","A9270","HCPCS","59762-3720-1","NDC","637","RC","","Facility","Outpatient","1","ME","1.04","1.04","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","101% of Medicare Fee Schedule","","","","1.04","Fee Schedule","","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.04","150","","","Percent of Total Billed Charges","neg_dollar:$1.61;150% of Medicaid interim rate","0.83","80","","","Percent of Total Billed Charges","neg_dollar:$0.83;Percent of Total Billed Charges","0.95","92","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LORAZEPAM 0.5 MG PO TABS","A9270","HCPCS","00904-6007-61","NDC","637","RC","","Facility","Outpatient","1","ME","0.10","0.10","","","","0.10","Fee Schedule","","","","","0.10","Fee Schedule","101% of Medicare Fee Schedule","","","","0.10","Fee Schedule","","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.08","86","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.06","70","","","Percent of Total Billed Charges","neg_dollar:$0.06","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.05;102% of Medicaid interim rate","0.07","75","","","Percent of Total Billed Charges","neg_dollar:$0.07","0.08","86","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.06","70","","","Percent of Total Billed Charges","neg_dollar:$0.06","0.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.05;103.5% of Medicaid interim rate","0.10","150","","","Percent of Total Billed Charges","neg_dollar:$0.15;150% of Medicaid interim rate","0.08","80","","","Percent of Total Billed Charges","neg_dollar:$0.08;Percent of Total Billed Charges","0.09","92","","","Percent of Total Billed Charges","neg_dollar:$0.09","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PRAMIPEXOLE DIHYDROCHLORIDE 0.5 MG PO TABS","A9270","HCPCS","60687-581-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.43","1.43","","","","1.43","Fee Schedule","","","","","1.43","Fee Schedule","101% of Medicare Fee Schedule","","","","1.43","Fee Schedule","","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","86","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.00","70","","","Percent of Total Billed Charges","neg_dollar:$1","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.84;102% of Medicaid interim rate","1.07","75","","","Percent of Total Billed Charges","neg_dollar:$1.07","1.23","86","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.00","70","","","Percent of Total Billed Charges","neg_dollar:$1","0.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.81;103.5% of Medicaid interim rate","1.43","150","","","Percent of Total Billed Charges","neg_dollar:$2.21;150% of Medicaid interim rate","1.14","80","","","Percent of Total Billed Charges","neg_dollar:$1.14;Percent of Total Billed Charges","1.31","92","","","Percent of Total Billed Charges","neg_dollar:$1.31","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CLONAZEPAM 0.5 MG PO TABS","A9270","HCPCS","60687-544-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.31","1.31","","","","1.31","Fee Schedule","","","","","1.31","Fee Schedule","101% of Medicare Fee Schedule","","","","1.31","Fee Schedule","","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.31","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.31","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.13","86","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","70","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% of Medicaid interim rate","0.98","75","","","Percent of Total Billed Charges","neg_dollar:$0.98","1.13","86","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","70","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.31","150","","","Percent of Total Billed Charges","neg_dollar:$2.03;150% of Medicaid interim rate","1.05","80","","","Percent of Total Billed Charges","neg_dollar:$1.05;Percent of Total Billed Charges","1.21","92","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CLONAZEPAM 0.5 MG PO TABS","A9270","HCPCS","60687-861-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","101% of Medicare Fee Schedule","","","","1.75","Fee Schedule","","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LORAZEPAM 0.5 MG PO TABS","A9270","HCPCS","69315-904-01","NDC","637","RC","","Facility","Outpatient","1","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","101% of Medicare Fee Schedule","","","","0.50","Fee Schedule","","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TAKE HOME LORAZEPAM 0.5 MG PO TABS (QTY:SIX)","A9270","HCPCS","63739-499-10","NDC","253","RC","","Facility","Outpatient","1","ME","11","11.00","11.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","11.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.45","86","","","Percent of Total Billed Charges","neg_dollar:$9.45","7.69","70","","","Percent of Total Billed Charges","neg_dollar:$7.69","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.46;102% of Medicaid interim rate","8.25","75","","","Percent of Total Billed Charges","neg_dollar:$8.25","9.45","86","","","Percent of Total Billed Charges","neg_dollar:$9.45","7.69","70","","","Percent of Total Billed Charges","neg_dollar:$7.69","6.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.27;103.5% of Medicaid interim rate","11.00","150","","","Percent of Total Billed Charges","neg_dollar:$17;150% of Medicaid interim rate","8.80","80","","","Percent of Total Billed Charges","neg_dollar:$8.80;Percent of Total Billed Charges","10.12","92","","","Percent of Total Billed Charges","neg_dollar:$10.12","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","11.00",""
"LATANOPROST 0.005 % OP SOLN","A9270","HCPCS","61314-547-01","NDC","250","RC","","Facility","Outpatient","1","UN","22.30","22.30","","","","22.30","Fee Schedule","","","","","22.30","Fee Schedule","","","","","22.30","Fee Schedule","","","52","","22.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.17","86","","","Percent of Total Billed Charges","neg_dollar:$19.17","15.61","70","","","Percent of Total Billed Charges","neg_dollar:$15.61","","52","","22.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.10;102% of Medicaid interim rate","16.72","75","","","Percent of Total Billed Charges","neg_dollar:$16.72","19.17","86","","","Percent of Total Billed Charges","neg_dollar:$19.17","15.61","70","","","Percent of Total Billed Charges","neg_dollar:$15.61","12.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.71;103.5% of Medicaid interim rate","22.30","150","","","Percent of Total Billed Charges","neg_dollar:$34.47;150% of Medicaid interim rate","17.84","80","","","Percent of Total Billed Charges","neg_dollar:$17.84;Percent of Total Billed Charges","20.51","92","","","Percent of Total Billed Charges","neg_dollar:$20.51","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","22.30","Fee Schedule","","11.00","22.00",""
"LATANOPROST 0.005 % OP SOLN","A9270","HCPCS","61314-547-01","NDC","637","RC","","Facility","Outpatient","1","UN","22.30","22.30","","","","22.30","Fee Schedule","","","","","22.30","Fee Schedule","101% of Medicare Fee Schedule","","","","22.30","Fee Schedule","","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","22.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","22.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","19.17","86","","","Percent of Total Billed Charges","neg_dollar:$19.17","15.61","70","","","Percent of Total Billed Charges","neg_dollar:$15.61","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.10;102% of Medicaid interim rate","16.72","75","","","Percent of Total Billed Charges","neg_dollar:$16.72","19.17","86","","","Percent of Total Billed Charges","neg_dollar:$19.17","15.61","70","","","Percent of Total Billed Charges","neg_dollar:$15.61","12.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.71;103.5% of Medicaid interim rate","22.30","150","","","Percent of Total Billed Charges","neg_dollar:$34.47;150% of Medicaid interim rate","17.84","80","","","Percent of Total Billed Charges","neg_dollar:$17.84;Percent of Total Billed Charges","20.51","92","","","Percent of Total Billed Charges","neg_dollar:$20.51","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.00","22.00",""
"OXYMETAZOLINE HCL 0.05 % NA SOLN","A9270","HCPCS","00904-7427-30","NDC","250","RC","","Facility","Outpatient","1","UN","13","13.00","","","","13.00","Fee Schedule","","","","","13.00","Fee Schedule","","","","","13.00","Fee Schedule","","","52","","13.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.76","52","","","Percent of Total Billed Charges","neg_dollar:$6.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.76","52","","","Percent of Total Billed Charges","neg_dollar:$6.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.18","86","","","Percent of Total Billed Charges","neg_dollar:$11.18","9.10","70","","","Percent of Total Billed Charges","neg_dollar:$9.10","","52","","13.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.63;102% of Medicaid interim rate","9.75","75","","","Percent of Total Billed Charges","neg_dollar:$9.75","11.18","86","","","Percent of Total Billed Charges","neg_dollar:$11.18","9.10","70","","","Percent of Total Billed Charges","neg_dollar:$9.10","7.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.40;103.5% of Medicaid interim rate","13.00","150","","","Percent of Total Billed Charges","neg_dollar:$20.09;150% of Medicaid interim rate","10.40","80","","","Percent of Total Billed Charges","neg_dollar:$10.40;Percent of Total Billed Charges","11.96","92","","","Percent of Total Billed Charges","neg_dollar:$11.96","6.76","52","","","Percent of Total Billed Charges","neg_dollar:$6.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","13.00","Fee Schedule","","6.00","13.00",""
"OXYMETAZOLINE HCL 0.05 % NA SOLN","A9270","HCPCS","46122-165-10","NDC","637","RC","","Facility","Outpatient","1","UN","13.60","13.60","","","","13.60","Fee Schedule","","","","","13.60","Fee Schedule","101% of Medicare Fee Schedule","","","","13.60","Fee Schedule","","7.07","52","","","Percent of Total Billed Charges","neg_dollar:$7.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.69","86","","","Percent of Total Billed Charges","neg_dollar:$11.69","9.52","70","","","Percent of Total Billed Charges","neg_dollar:$9.52","7.07","52","","","Percent of Total Billed Charges","neg_dollar:$7.07;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.98;102% of Medicaid interim rate","10.20","75","","","Percent of Total Billed Charges","neg_dollar:$10.20","11.69","86","","","Percent of Total Billed Charges","neg_dollar:$11.69","9.52","70","","","Percent of Total Billed Charges","neg_dollar:$9.52","7.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.75;103.5% of Medicaid interim rate","13.60","150","","","Percent of Total Billed Charges","neg_dollar:$21.02;150% of Medicaid interim rate","10.88","80","","","Percent of Total Billed Charges","neg_dollar:$10.88;Percent of Total Billed Charges","12.51","92","","","Percent of Total Billed Charges","neg_dollar:$12.51","7.07","52","","","Percent of Total Billed Charges","neg_dollar:$7.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.07","52","","","Percent of Total Billed Charges","neg_dollar:$7.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","13.00",""
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA","A9270","HCPCS","33342-329-54","NDC","250","RC","","Facility","Outpatient","1","UN","38","38.00","","","","38.00","Fee Schedule","","","","","38.00","Fee Schedule","","","","","38.00","Fee Schedule","","","52","","38.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.68","86","","","Percent of Total Billed Charges","neg_dollar:$32.68","26.59","70","","","Percent of Total Billed Charges","neg_dollar:$26.59","","52","","38.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","22.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.32;102% of Medicaid interim rate","28.50","75","","","Percent of Total Billed Charges","neg_dollar:$28.50","32.68","86","","","Percent of Total Billed Charges","neg_dollar:$32.68","26.59","70","","","Percent of Total Billed Charges","neg_dollar:$26.59","21.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.65;103.5% of Medicaid interim rate","38.00","150","","","Percent of Total Billed Charges","neg_dollar:$58.74;150% of Medicaid interim rate","30.40","80","","","Percent of Total Billed Charges","neg_dollar:$30.40;Percent of Total Billed Charges","34.96","92","","","Percent of Total Billed Charges","neg_dollar:$34.96","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","38.00","Fee Schedule","","19.00","38.00",""
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA","A9270","HCPCS","45802-064-35","NDC","250","RC","","Facility","Outpatient","1","UN","14.10","14.10","","","","14.10","Fee Schedule","","","","","14.10","Fee Schedule","","","","","14.10","Fee Schedule","","","52","","14.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.33","52","","","Percent of Total Billed Charges","neg_dollar:$7.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.33","52","","","Percent of Total Billed Charges","neg_dollar:$7.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.12","86","","","Percent of Total Billed Charges","neg_dollar:$12.12","9.87","70","","","Percent of Total Billed Charges","neg_dollar:$9.87","","52","","14.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.28;102% of Medicaid interim rate","10.57","75","","","Percent of Total Billed Charges","neg_dollar:$10.57","12.12","86","","","Percent of Total Billed Charges","neg_dollar:$12.12","9.87","70","","","Percent of Total Billed Charges","neg_dollar:$9.87","8.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.03;103.5% of Medicaid interim rate","14.10","150","","","Percent of Total Billed Charges","neg_dollar:$21.79;150% of Medicaid interim rate","11.28","80","","","Percent of Total Billed Charges","neg_dollar:$11.28;Percent of Total Billed Charges","12.97","92","","","Percent of Total Billed Charges","neg_dollar:$12.97","7.33","52","","","Percent of Total Billed Charges","neg_dollar:$7.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","14.10","Fee Schedule","","7.00","14.00",""
"FLUDROCORTISONE ACETATE 0.1 MG PO TABS","A9270","HCPCS","50268-330-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA","A9270","HCPCS","00168-0004-16","NDC","637","RC","","Facility","Outpatient","1","UN","32.50","32.50","","","","32.50","Fee Schedule","","","","","32.50","Fee Schedule","101% of Medicare Fee Schedule","","","","32.50","Fee Schedule","","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","32.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","32.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","27.95","86","","","Percent of Total Billed Charges","neg_dollar:$27.95","22.75","70","","","Percent of Total Billed Charges","neg_dollar:$22.75","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.09;102% of Medicaid interim rate","24.37","75","","","Percent of Total Billed Charges","neg_dollar:$24.37","27.95","86","","","Percent of Total Billed Charges","neg_dollar:$27.95","22.75","70","","","Percent of Total Billed Charges","neg_dollar:$22.75","18.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.52;103.5% of Medicaid interim rate","32.50","150","","","Percent of Total Billed Charges","neg_dollar:$50.24;150% of Medicaid interim rate","26.00","80","","","Percent of Total Billed Charges","neg_dollar:$26;Percent of Total Billed Charges","29.90","92","","","Percent of Total Billed Charges","neg_dollar:$29.90","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","32.00",""
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA","A9270","HCPCS","45802-064-35","NDC","637","RC","","Facility","Outpatient","1","UN","14.10","14.10","","","","14.10","Fee Schedule","","","","","14.10","Fee Schedule","101% of Medicare Fee Schedule","","","","14.10","Fee Schedule","","7.33","52","","","Percent of Total Billed Charges","neg_dollar:$7.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","14.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","14.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.12","86","","","Percent of Total Billed Charges","neg_dollar:$12.12","9.87","70","","","Percent of Total Billed Charges","neg_dollar:$9.87","7.33","52","","","Percent of Total Billed Charges","neg_dollar:$7.33;105% Medicare Outpatient Cost to Charge Ratio of 52%","8.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.28;102% of Medicaid interim rate","10.57","75","","","Percent of Total Billed Charges","neg_dollar:$10.57","12.12","86","","","Percent of Total Billed Charges","neg_dollar:$12.12","9.87","70","","","Percent of Total Billed Charges","neg_dollar:$9.87","8.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.03;103.5% of Medicaid interim rate","14.10","150","","","Percent of Total Billed Charges","neg_dollar:$21.79;150% of Medicaid interim rate","11.28","80","","","Percent of Total Billed Charges","neg_dollar:$11.28;Percent of Total Billed Charges","12.97","92","","","Percent of Total Billed Charges","neg_dollar:$12.97","7.33","52","","","Percent of Total Billed Charges","neg_dollar:$7.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.33","52","","","Percent of Total Billed Charges","neg_dollar:$7.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","14.00",""
"FLUDROCORTISONE ACETATE 0.1 MG PO TABS","A9270","HCPCS","50268-330-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","101% of Medicare Fee Schedule","","","","1.60","Fee Schedule","","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % OP SOLN","A9270","HCPCS","57896-181-05","NDC","250","RC","","Facility","Outpatient","1","UN","12.40","12.40","","","","12.40","Fee Schedule","","","","","12.40","Fee Schedule","","","","","12.40","Fee Schedule","","","52","","12.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.44","52","","","Percent of Total Billed Charges","neg_dollar:$6.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.44","52","","","Percent of Total Billed Charges","neg_dollar:$6.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.66","86","","","Percent of Total Billed Charges","neg_dollar:$10.66","8.68","70","","","Percent of Total Billed Charges","neg_dollar:$8.68","","52","","12.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.28;102% of Medicaid interim rate","9.30","75","","","Percent of Total Billed Charges","neg_dollar:$9.30","10.66","86","","","Percent of Total Billed Charges","neg_dollar:$10.66","8.68","70","","","Percent of Total Billed Charges","neg_dollar:$8.68","7.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.06;103.5% of Medicaid interim rate","12.40","150","","","Percent of Total Billed Charges","neg_dollar:$19.17;150% of Medicaid interim rate","9.92","80","","","Percent of Total Billed Charges","neg_dollar:$9.92;Percent of Total Billed Charges","11.40","92","","","Percent of Total Billed Charges","neg_dollar:$11.40","6.44","52","","","Percent of Total Billed Charges","neg_dollar:$6.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.40","Fee Schedule","","6.00","12.00",""
"GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % OP SOLN","A9270","HCPCS","57896-184-05","NDC","250","RC","","Facility","Outpatient","1","UN","11.95","11.95","","","","11.95","Fee Schedule","","","","","11.95","Fee Schedule","","","","","11.95","Fee Schedule","","","52","","11.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","","52","","11.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.02;102% of Medicaid interim rate","8.96","75","","","Percent of Total Billed Charges","neg_dollar:$8.96","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.81;103.5% of Medicaid interim rate","11.95","150","","","Percent of Total Billed Charges","neg_dollar:$18.47;150% of Medicaid interim rate","9.56","80","","","Percent of Total Billed Charges","neg_dollar:$9.56;Percent of Total Billed Charges","10.99","92","","","Percent of Total Billed Charges","neg_dollar:$10.99","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","11.95","Fee Schedule","","6.00","11.00",""
"GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % OP SOLN","A9270","HCPCS","57896-184-05","NDC","637","RC","","Facility","Outpatient","1","UN","11.95","11.95","","","","11.95","Fee Schedule","","","","","11.95","Fee Schedule","101% of Medicare Fee Schedule","","","","11.95","Fee Schedule","","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.02;102% of Medicaid interim rate","8.96","75","","","Percent of Total Billed Charges","neg_dollar:$8.96","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.81;103.5% of Medicaid interim rate","11.95","150","","","Percent of Total Billed Charges","neg_dollar:$18.47;150% of Medicaid interim rate","9.56","80","","","Percent of Total Billed Charges","neg_dollar:$9.56;Percent of Total Billed Charges","10.99","92","","","Percent of Total Billed Charges","neg_dollar:$10.99","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","11.00",""
"GLYCERIN-HYPROMELLOSE-PEG 400 0.2-0.2-1 % OP SOLN","A9270","HCPCS","57896-181-05","NDC","637","RC","","Facility","Outpatient","1","UN","12.40","12.40","","","","12.40","Fee Schedule","","","","","12.40","Fee Schedule","101% of Medicare Fee Schedule","","","","12.40","Fee Schedule","","6.44","52","","","Percent of Total Billed Charges","neg_dollar:$6.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.66","86","","","Percent of Total Billed Charges","neg_dollar:$10.66","8.68","70","","","Percent of Total Billed Charges","neg_dollar:$8.68","6.44","52","","","Percent of Total Billed Charges","neg_dollar:$6.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.28;102% of Medicaid interim rate","9.30","75","","","Percent of Total Billed Charges","neg_dollar:$9.30","10.66","86","","","Percent of Total Billed Charges","neg_dollar:$10.66","8.68","70","","","Percent of Total Billed Charges","neg_dollar:$8.68","7.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.06;103.5% of Medicaid interim rate","12.40","150","","","Percent of Total Billed Charges","neg_dollar:$19.17;150% of Medicaid interim rate","9.92","80","","","Percent of Total Billed Charges","neg_dollar:$9.92;Percent of Total Billed Charges","11.40","92","","","Percent of Total Billed Charges","neg_dollar:$11.40","6.44","52","","","Percent of Total Billed Charges","neg_dollar:$6.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.44","52","","","Percent of Total Billed Charges","neg_dollar:$6.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","12.00",""
"TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT","A9270","HCPCS","00078-0876-01","NDC","250","RC","","Facility","Outpatient","1","UN","308.90","308.90","","","","308.90","Fee Schedule","","","","","308.90","Fee Schedule","","","","","308.90","Fee Schedule","","","52","","308.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","160.62","52","","","Percent of Total Billed Charges","neg_dollar:$160.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","160.62","52","","","Percent of Total Billed Charges","neg_dollar:$160.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","265.65","86","","","Percent of Total Billed Charges","neg_dollar:$265.65","216.22","70","","","Percent of Total Billed Charges","neg_dollar:$216.22","","52","","308.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","181.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$181.47;102% of Medicaid interim rate","231.67","75","","","Percent of Total Billed Charges","neg_dollar:$231.67","265.65","86","","","Percent of Total Billed Charges","neg_dollar:$265.65","216.22","70","","","Percent of Total Billed Charges","neg_dollar:$216.22","176.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$176.07;103.5% of Medicaid interim rate","308.90","150","","","Percent of Total Billed Charges","neg_dollar:$477.57;150% of Medicaid interim rate","247.12","80","","","Percent of Total Billed Charges","neg_dollar:$247.12;Percent of Total Billed Charges","284.18","92","","","Percent of Total Billed Charges","neg_dollar:$284.18","160.62","52","","","Percent of Total Billed Charges","neg_dollar:$160.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","308.90","Fee Schedule","","160.00","308.00",""
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP","A9270","HCPCS","72485-625-13","NDC","637","RC","","Facility","Outpatient","1","UN","137.45","137.45","","","","137.45","Fee Schedule","","","","","137.45","Fee Schedule","101% of Medicare Fee Schedule","","","","137.45","Fee Schedule","","71.47","52","","","Percent of Total Billed Charges","neg_dollar:$71.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","137.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","137.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","118.20","86","","","Percent of Total Billed Charges","neg_dollar:$118.20","96.21","70","","","Percent of Total Billed Charges","neg_dollar:$96.21","71.47","52","","","Percent of Total Billed Charges","neg_dollar:$71.47;105% Medicare Outpatient Cost to Charge Ratio of 52%","80.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$80.75;102% of Medicaid interim rate","103.08","75","","","Percent of Total Billed Charges","neg_dollar:$103.08","118.20","86","","","Percent of Total Billed Charges","neg_dollar:$118.20","96.21","70","","","Percent of Total Billed Charges","neg_dollar:$96.21","78.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$78.34;103.5% of Medicaid interim rate","137.45","150","","","Percent of Total Billed Charges","neg_dollar:$212.50;150% of Medicaid interim rate","109.96","80","","","Percent of Total Billed Charges","neg_dollar:$109.96;Percent of Total Billed Charges","126.45","92","","","Percent of Total Billed Charges","neg_dollar:$126.45","71.47","52","","","Percent of Total Billed Charges","neg_dollar:$71.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","71.47","52","","","Percent of Total Billed Charges","neg_dollar:$71.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","71.00","137.00",""
"KETOROLAC TROMETHAMINE 0.5 % OP SOLN","A9270","HCPCS","61314-126-05","NDC","250","RC","","Facility","Outpatient","1","UN","41.30","41.30","","","","41.30","Fee Schedule","","","","","41.30","Fee Schedule","","","","","41.30","Fee Schedule","","","52","","41.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","21.47","52","","","Percent of Total Billed Charges","neg_dollar:$21.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.47","52","","","Percent of Total Billed Charges","neg_dollar:$21.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","35.51","86","","","Percent of Total Billed Charges","neg_dollar:$35.51","28.90","70","","","Percent of Total Billed Charges","neg_dollar:$28.90","","52","","41.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","24.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.26;102% of Medicaid interim rate","30.97","75","","","Percent of Total Billed Charges","neg_dollar:$30.97","35.51","86","","","Percent of Total Billed Charges","neg_dollar:$35.51","28.90","70","","","Percent of Total Billed Charges","neg_dollar:$28.90","23.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$23.54;103.5% of Medicaid interim rate","41.30","150","","","Percent of Total Billed Charges","neg_dollar:$63.85;150% of Medicaid interim rate","33.04","80","","","Percent of Total Billed Charges","neg_dollar:$33.04;Percent of Total Billed Charges","37.99","92","","","Percent of Total Billed Charges","neg_dollar:$37.99","21.47","52","","","Percent of Total Billed Charges","neg_dollar:$21.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","41.30","Fee Schedule","","21.00","41.00",""
"COLCHICINE 0.6 MG PO TABS","A9270","HCPCS","60687-727-11","NDC","250","RC","","Facility","Outpatient","1","ME","12.20","12.20","","","","12.20","Fee Schedule","","","","","12.20","Fee Schedule","","","","","12.20","Fee Schedule","","","52","","12.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.34","52","","","Percent of Total Billed Charges","neg_dollar:$6.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.34","52","","","Percent of Total Billed Charges","neg_dollar:$6.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.49","86","","","Percent of Total Billed Charges","neg_dollar:$10.49","8.54","70","","","Percent of Total Billed Charges","neg_dollar:$8.54","","52","","12.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.16;102% of Medicaid interim rate","9.14","75","","","Percent of Total Billed Charges","neg_dollar:$9.14","10.49","86","","","Percent of Total Billed Charges","neg_dollar:$10.49","8.54","70","","","Percent of Total Billed Charges","neg_dollar:$8.54","6.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.95;103.5% of Medicaid interim rate","12.20","150","","","Percent of Total Billed Charges","neg_dollar:$18.86;150% of Medicaid interim rate","9.76","80","","","Percent of Total Billed Charges","neg_dollar:$9.76;Percent of Total Billed Charges","11.22","92","","","Percent of Total Billed Charges","neg_dollar:$11.22","6.34","52","","","Percent of Total Billed Charges","neg_dollar:$6.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.20","Fee Schedule","","6.00","12.00",""
"COLCHICINE 0.6 MG PO TABS","A9270","HCPCS","49884-171-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.62","1.62","","","","1.62","Fee Schedule","","","","","1.62","Fee Schedule","101% of Medicare Fee Schedule","","","","1.62","Fee Schedule","","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.39","86","","","Percent of Total Billed Charges","neg_dollar:$1.39","1.13","70","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% of Medicaid interim rate","1.21","75","","","Percent of Total Billed Charges","neg_dollar:$1.21","1.39","86","","","Percent of Total Billed Charges","neg_dollar:$1.39","1.13","70","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.92;103.5% of Medicaid interim rate","1.62","150","","","Percent of Total Billed Charges","neg_dollar:$2.51;150% of Medicaid interim rate","1.30","80","","","Percent of Total Billed Charges","neg_dollar:$1.30;Percent of Total Billed Charges","1.49","92","","","Percent of Total Billed Charges","neg_dollar:$1.49","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SUCRALFATE 1 G PO TABS","A9270","HCPCS","51079-753-20","NDC","250","RC","","Facility","Outpatient","1","GM","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"PRAZOSIN HCL 1 MG PO CAPS","A9270","HCPCS","00093-4067-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.55","Fee Schedule","","1.00","1.00",""
"DICLOFENAC SODIUM 1 % EX GEL","A9270","HCPCS","00067-8152-03","NDC","250","RC","","Facility","Outpatient","1","UN","25.50","25.50","","","","25.50","Fee Schedule","","","","","25.50","Fee Schedule","","","","","25.50","Fee Schedule","","","52","","25.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.26","52","","","Percent of Total Billed Charges","neg_dollar:$13.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.26","52","","","Percent of Total Billed Charges","neg_dollar:$13.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.93","86","","","Percent of Total Billed Charges","neg_dollar:$21.93","17.84","70","","","Percent of Total Billed Charges","neg_dollar:$17.84","","52","","25.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.98;102% of Medicaid interim rate","19.12","75","","","Percent of Total Billed Charges","neg_dollar:$19.12","21.93","86","","","Percent of Total Billed Charges","neg_dollar:$21.93","17.84","70","","","Percent of Total Billed Charges","neg_dollar:$17.84","14.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.53;103.5% of Medicaid interim rate","25.50","150","","","Percent of Total Billed Charges","neg_dollar:$39.42;150% of Medicaid interim rate","20.40","80","","","Percent of Total Billed Charges","neg_dollar:$20.40;Percent of Total Billed Charges","23.46","92","","","Percent of Total Billed Charges","neg_dollar:$23.46","13.26","52","","","Percent of Total Billed Charges","neg_dollar:$13.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.50","Fee Schedule","","13.00","25.00",""
"BENZTROPINE MESYLATE 1 MG PO TABS","A9270","HCPCS","00440-7195-30","NDC","250","RC","","Facility","Outpatient","1","ME","0.67","0.67","","","","0.67","Fee Schedule","","","","","0.67","Fee Schedule","","","","","0.67","Fee Schedule","","","52","","0.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","86","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.47","70","","","Percent of Total Billed Charges","neg_dollar:$0.47","","52","","0.67","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% of Medicaid interim rate","0.50","75","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.58","86","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.47","70","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.38;103.5% of Medicaid interim rate","0.67","150","","","Percent of Total Billed Charges","neg_dollar:$1.04;150% of Medicaid interim rate","0.54","80","","","Percent of Total Billed Charges","neg_dollar:$0.54;Percent of Total Billed Charges","0.62","92","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.67","Fee Schedule","","1.00","1.00",""
"ROPINIROLE HCL 1 MG PO TABS","A9270","HCPCS","00904-6374-61","NDC","250","RC","","Facility","Outpatient","1","ME","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","","52","","1.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.70","Fee Schedule","","1.00","1.00",""
"DICLOFENAC SODIUM 1 % EX GEL","A9270","HCPCS","43598-977-10","NDC","250","RC","","Facility","Outpatient","1","UN","23.70","23.70","","","","23.70","Fee Schedule","","","","","23.70","Fee Schedule","","","","","23.70","Fee Schedule","","","52","","23.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.38","86","","","Percent of Total Billed Charges","neg_dollar:$20.38","16.59","70","","","Percent of Total Billed Charges","neg_dollar:$16.59","","52","","23.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.92;102% of Medicaid interim rate","17.77","75","","","Percent of Total Billed Charges","neg_dollar:$17.77","20.38","86","","","Percent of Total Billed Charges","neg_dollar:$20.38","16.59","70","","","Percent of Total Billed Charges","neg_dollar:$16.59","13.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.50;103.5% of Medicaid interim rate","23.70","150","","","Percent of Total Billed Charges","neg_dollar:$36.64;150% of Medicaid interim rate","18.96","80","","","Percent of Total Billed Charges","neg_dollar:$18.96;Percent of Total Billed Charges","21.80","92","","","Percent of Total Billed Charges","neg_dollar:$21.80","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","23.70","Fee Schedule","","12.00","23.00",""
"WARFARIN SODIUM 1 MG PO TABS","A9270","HCPCS","00832-1211-89","NDC","250","RC","","Facility","Outpatient","1","ME","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","","52","","1.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.45","Fee Schedule","","1.00","1.00",""
"DICLOFENAC SODIUM 1 % EX GEL","A9270","HCPCS","45802-953-01","NDC","250","RC","","Facility","Outpatient","1","UN","24.05","24.05","","","","24.05","Fee Schedule","","","","","24.05","Fee Schedule","","","","","24.05","Fee Schedule","","","52","","24.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.50","52","","","Percent of Total Billed Charges","neg_dollar:$12.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.50","52","","","Percent of Total Billed Charges","neg_dollar:$12.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.68","86","","","Percent of Total Billed Charges","neg_dollar:$20.68","16.83","70","","","Percent of Total Billed Charges","neg_dollar:$16.83","","52","","24.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.12;102% of Medicaid interim rate","18.03","75","","","Percent of Total Billed Charges","neg_dollar:$18.03","20.68","86","","","Percent of Total Billed Charges","neg_dollar:$20.68","16.83","70","","","Percent of Total Billed Charges","neg_dollar:$16.83","13.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.70;103.5% of Medicaid interim rate","24.05","150","","","Percent of Total Billed Charges","neg_dollar:$37.18;150% of Medicaid interim rate","19.24","80","","","Percent of Total Billed Charges","neg_dollar:$19.24;Percent of Total Billed Charges","22.12","92","","","Percent of Total Billed Charges","neg_dollar:$22.12","12.50","52","","","Percent of Total Billed Charges","neg_dollar:$12.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","24.05","Fee Schedule","","12.00","24.00",""
"SUCRALFATE 1 G PO TABS","A9270","HCPCS","51079-753-01","NDC","250","RC","","Facility","Outpatient","1","GM","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"ROPINIROLE HCL 1 MG PO TABS","A9270","HCPCS","60687-588-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.34","1.34","","","","1.34","Fee Schedule","","","","","1.34","Fee Schedule","","","","","1.34","Fee Schedule","","","52","","1.34","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.15","86","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.93","70","","","Percent of Total Billed Charges","neg_dollar:$0.93","","52","","1.34","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% of Medicaid interim rate","1.00","75","","","Percent of Total Billed Charges","neg_dollar:$1","1.15","86","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.93","70","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.34","150","","","Percent of Total Billed Charges","neg_dollar:$2.07;150% of Medicaid interim rate","1.07","80","","","Percent of Total Billed Charges","neg_dollar:$1.07;Percent of Total Billed Charges","1.23","92","","","Percent of Total Billed Charges","neg_dollar:$1.23","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.34","Fee Schedule","","1.00","1.00",""
"PREDNISOLONE ACETATE 1 % OP SUSP","A9270","HCPCS","60758-119-05","NDC","250","RC","","Facility","Outpatient","1","UN","58.90","58.90","","","","58.90","Fee Schedule","","","","","58.90","Fee Schedule","","","","","58.90","Fee Schedule","","","52","","58.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","30.62","52","","","Percent of Total Billed Charges","neg_dollar:$30.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.62","52","","","Percent of Total Billed Charges","neg_dollar:$30.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.65","86","","","Percent of Total Billed Charges","neg_dollar:$50.65","41.23","70","","","Percent of Total Billed Charges","neg_dollar:$41.23","","52","","58.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","34.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.60;102% of Medicaid interim rate","44.17","75","","","Percent of Total Billed Charges","neg_dollar:$44.17","50.65","86","","","Percent of Total Billed Charges","neg_dollar:$50.65","41.23","70","","","Percent of Total Billed Charges","neg_dollar:$41.23","33.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.57;103.5% of Medicaid interim rate","58.90","150","","","Percent of Total Billed Charges","neg_dollar:$91.06;150% of Medicaid interim rate","47.12","80","","","Percent of Total Billed Charges","neg_dollar:$47.12;Percent of Total Billed Charges","54.18","92","","","Percent of Total Billed Charges","neg_dollar:$54.18","30.62","52","","","Percent of Total Billed Charges","neg_dollar:$30.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","58.90","Fee Schedule","","30.00","58.00",""
"ATROPINE SULFATE 1 % OP SOLN","A9270","HCPCS","60219-1748-2","NDC","250","RC","","Facility","Outpatient","1","UN","50","50.00","","","","50.00","Fee Schedule","","","","","50.00","Fee Schedule","","","","","50.00","Fee Schedule","","","52","","50.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;102% Medicare Outpatient Cost to Charge Ratio of 52%","43.00","86","","","Percent of Total Billed Charges","neg_dollar:$43","35.00","70","","","Percent of Total Billed Charges","neg_dollar:$35","","52","","50.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","29.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.37;102% of Medicaid interim rate","37.50","75","","","Percent of Total Billed Charges","neg_dollar:$37.50","43.00","86","","","Percent of Total Billed Charges","neg_dollar:$43","35.00","70","","","Percent of Total Billed Charges","neg_dollar:$35","28.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.49;103.5% of Medicaid interim rate","50.00","150","","","Percent of Total Billed Charges","neg_dollar:$77.30;150% of Medicaid interim rate","40.00","80","","","Percent of Total Billed Charges","neg_dollar:$40;Percent of Total Billed Charges","46.00","92","","","Percent of Total Billed Charges","neg_dollar:$46","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","50.00","Fee Schedule","","26.00","50.00",""
"FOLIC ACID 1 MG PO TABS","A9270","HCPCS","60687-681-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"PREDNISOLONE ACETATE 1 % OP SUSP","A9270","HCPCS","61314-637-05","NDC","250","RC","","Facility","Outpatient","1","UN","59.20","59.20","","","","59.20","Fee Schedule","","","","","59.20","Fee Schedule","","","","","59.20","Fee Schedule","","","52","","59.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","30.78","52","","","Percent of Total Billed Charges","neg_dollar:$30.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.78","52","","","Percent of Total Billed Charges","neg_dollar:$30.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.91","86","","","Percent of Total Billed Charges","neg_dollar:$50.91","41.44","70","","","Percent of Total Billed Charges","neg_dollar:$41.44","","52","","59.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","34.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.77;102% of Medicaid interim rate","44.40","75","","","Percent of Total Billed Charges","neg_dollar:$44.40","50.91","86","","","Percent of Total Billed Charges","neg_dollar:$50.91","41.44","70","","","Percent of Total Billed Charges","neg_dollar:$41.44","33.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.74;103.5% of Medicaid interim rate","59.20","150","","","Percent of Total Billed Charges","neg_dollar:$91.52;150% of Medicaid interim rate","47.36","80","","","Percent of Total Billed Charges","neg_dollar:$47.36;Percent of Total Billed Charges","54.46","92","","","Percent of Total Billed Charges","neg_dollar:$54.46","30.78","52","","","Percent of Total Billed Charges","neg_dollar:$30.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","59.20","Fee Schedule","","30.00","59.00",""
"SODIUM CHLORIDE 1 G PO TABS","A9270","HCPCS","77333-844-25","NDC","250","RC","","Facility","Outpatient","1","GM","3.90","3.90","","","","3.90","Fee Schedule","","","","","3.90","Fee Schedule","","","","","3.90","Fee Schedule","","","52","","3.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.35","86","","","Percent of Total Billed Charges","neg_dollar:$3.35","2.73","70","","","Percent of Total Billed Charges","neg_dollar:$2.73","","52","","3.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.29;102% of Medicaid interim rate","2.92","75","","","Percent of Total Billed Charges","neg_dollar:$2.92","3.35","86","","","Percent of Total Billed Charges","neg_dollar:$3.35","2.73","70","","","Percent of Total Billed Charges","neg_dollar:$2.73","2.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.22;103.5% of Medicaid interim rate","3.90","150","","","Percent of Total Billed Charges","neg_dollar:$6.02;150% of Medicaid interim rate","3.12","80","","","Percent of Total Billed Charges","neg_dollar:$3.12;Percent of Total Billed Charges","3.58","92","","","Percent of Total Billed Charges","neg_dollar:$3.58","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.90","Fee Schedule","","2.00","3.00",""
"BUMETANIDE 1 MG PO TABS","A9270","HCPCS","50268-131-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.48","1.48","","","","1.48","Fee Schedule","","","","","1.48","Fee Schedule","","","","","1.48","Fee Schedule","","","52","","1.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","52","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","52","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.27","86","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","","52","","1.48","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.87;102% of Medicaid interim rate","1.11","75","","","Percent of Total Billed Charges","neg_dollar:$1.11","1.27","86","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.84;103.5% of Medicaid interim rate","1.48","150","","","Percent of Total Billed Charges","neg_dollar:$2.29;150% of Medicaid interim rate","1.18","80","","","Percent of Total Billed Charges","neg_dollar:$1.18;Percent of Total Billed Charges","1.36","92","","","Percent of Total Billed Charges","neg_dollar:$1.36","0.77","52","","","Percent of Total Billed Charges","neg_dollar:$0.77;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.48","Fee Schedule","","1.00","1.00",""
"SUCRALFATE 1 GM/10ML PO SUSP","A9270","HCPCS","60687-738-56","NDC","250","RC","","Facility","Outpatient","1","UN","20.50","20.50","","","","20.50","Fee Schedule","","","","","20.50","Fee Schedule","","","","","20.50","Fee Schedule","","","52","","20.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.66","52","","","Percent of Total Billed Charges","neg_dollar:$10.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.66","52","","","Percent of Total Billed Charges","neg_dollar:$10.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.63","86","","","Percent of Total Billed Charges","neg_dollar:$17.63","14.35","70","","","Percent of Total Billed Charges","neg_dollar:$14.35","","52","","20.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","12.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.04;102% of Medicaid interim rate","15.37","75","","","Percent of Total Billed Charges","neg_dollar:$15.37","17.63","86","","","Percent of Total Billed Charges","neg_dollar:$17.63","14.35","70","","","Percent of Total Billed Charges","neg_dollar:$14.35","11.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.68;103.5% of Medicaid interim rate","20.50","150","","","Percent of Total Billed Charges","neg_dollar:$31.69;150% of Medicaid interim rate","16.40","80","","","Percent of Total Billed Charges","neg_dollar:$16.40;Percent of Total Billed Charges","18.86","92","","","Percent of Total Billed Charges","neg_dollar:$18.86","10.66","52","","","Percent of Total Billed Charges","neg_dollar:$10.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","20.50","Fee Schedule","","10.00","20.00",""
"RISPERIDONE 1 MG PO TABS","A9270","HCPCS","68084-272-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.48","1.48","","","","1.48","Fee Schedule","","","","","1.48","Fee Schedule","","","","","1.48","Fee Schedule","","","52","","1.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.27","86","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","","52","","1.48","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.86;102% of Medicaid interim rate","1.10","75","","","Percent of Total Billed Charges","neg_dollar:$1.10","1.27","86","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.84;103.5% of Medicaid interim rate","1.48","150","","","Percent of Total Billed Charges","neg_dollar:$2.28;150% of Medicaid interim rate","1.18","80","","","Percent of Total Billed Charges","neg_dollar:$1.18;Percent of Total Billed Charges","1.36","92","","","Percent of Total Billed Charges","neg_dollar:$1.36","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.48","Fee Schedule","","1.00","1.00",""
"BENZTROPINE MESYLATE 1 MG PO TABS","A9270","HCPCS","00440-7195-30","NDC","637","RC","","Facility","Outpatient","1","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ROPINIROLE HCL 1 MG PO TABS","A9270","HCPCS","00904-6374-61","NDC","637","RC","","Facility","Outpatient","1","ME","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","101% of Medicare Fee Schedule","","","","1.70","Fee Schedule","","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HALOPERIDOL 1 MG PO TABS","A9270","HCPCS","51079-734-01","NDC","637","RC","","Facility","Outpatient","1","ME","1.21","1.21","","","","1.21","Fee Schedule","","","","","1.21","Fee Schedule","101% of Medicare Fee Schedule","","","","1.21","Fee Schedule","","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","86","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% of Medicaid interim rate","0.91","75","","","Percent of Total Billed Charges","neg_dollar:$0.91","1.04","86","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;103.5% of Medicaid interim rate","1.21","150","","","Percent of Total Billed Charges","neg_dollar:$1.87;150% of Medicaid interim rate","0.97","80","","","Percent of Total Billed Charges","neg_dollar:$0.97;Percent of Total Billed Charges","1.11","92","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ROPINIROLE HCL 1 MG PO TABS","A9270","HCPCS","60687-588-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","101% of Medicare Fee Schedule","","","","1.70","Fee Schedule","","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SUCRALFATE 1 GM/10ML PO SUSP","A9270","HCPCS","60687-738-56","NDC","637","RC","","Facility","Outpatient","1","UN","20.50","20.50","","","","20.50","Fee Schedule","","","","","20.50","Fee Schedule","101% of Medicare Fee Schedule","","","","20.50","Fee Schedule","","10.66","52","","","Percent of Total Billed Charges","neg_dollar:$10.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.63","86","","","Percent of Total Billed Charges","neg_dollar:$17.63","14.35","70","","","Percent of Total Billed Charges","neg_dollar:$14.35","10.66","52","","","Percent of Total Billed Charges","neg_dollar:$10.66;105% Medicare Outpatient Cost to Charge Ratio of 52%","12.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.04;102% of Medicaid interim rate","15.37","75","","","Percent of Total Billed Charges","neg_dollar:$15.37","17.63","86","","","Percent of Total Billed Charges","neg_dollar:$17.63","14.35","70","","","Percent of Total Billed Charges","neg_dollar:$14.35","11.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.68;103.5% of Medicaid interim rate","20.50","150","","","Percent of Total Billed Charges","neg_dollar:$31.69;150% of Medicaid interim rate","16.40","80","","","Percent of Total Billed Charges","neg_dollar:$16.40;Percent of Total Billed Charges","18.86","92","","","Percent of Total Billed Charges","neg_dollar:$18.86","10.66","52","","","Percent of Total Billed Charges","neg_dollar:$10.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.66","52","","","Percent of Total Billed Charges","neg_dollar:$10.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.00","20.00",""
"RISPERIDONE 1 MG PO TABS","A9270","HCPCS","68084-272-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.48","1.48","","","","1.48","Fee Schedule","","","","","1.48","Fee Schedule","101% of Medicare Fee Schedule","","","","1.48","Fee Schedule","","0.77","52","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.27","86","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.77","52","","","Percent of Total Billed Charges","neg_dollar:$0.77;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.87;102% of Medicaid interim rate","1.11","75","","","Percent of Total Billed Charges","neg_dollar:$1.11","1.27","86","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.84;103.5% of Medicaid interim rate","1.48","150","","","Percent of Total Billed Charges","neg_dollar:$2.30;150% of Medicaid interim rate","1.19","80","","","Percent of Total Billed Charges","neg_dollar:$1.19;Percent of Total Billed Charges","1.36","92","","","Percent of Total Billed Charges","neg_dollar:$1.36","0.77","52","","","Percent of Total Billed Charges","neg_dollar:$0.77;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","52","","","Percent of Total Billed Charges","neg_dollar:$0.77;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FOLIC ACID 1 MG PO TABS","A9270","HCPCS","60687-681-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DICLOFENAC SODIUM 1 % EX GEL","A9270","HCPCS","43598-977-10","NDC","637","RC","","Facility","Outpatient","1","UN","23.70","23.70","","","","23.70","Fee Schedule","","","","","23.70","Fee Schedule","101% of Medicare Fee Schedule","","","","23.70","Fee Schedule","","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.38","86","","","Percent of Total Billed Charges","neg_dollar:$20.38","16.59","70","","","Percent of Total Billed Charges","neg_dollar:$16.59","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.92;102% of Medicaid interim rate","17.77","75","","","Percent of Total Billed Charges","neg_dollar:$17.77","20.38","86","","","Percent of Total Billed Charges","neg_dollar:$20.38","16.59","70","","","Percent of Total Billed Charges","neg_dollar:$16.59","13.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.50;103.5% of Medicaid interim rate","23.70","150","","","Percent of Total Billed Charges","neg_dollar:$36.64;150% of Medicaid interim rate","18.96","80","","","Percent of Total Billed Charges","neg_dollar:$18.96;Percent of Total Billed Charges","21.80","92","","","Percent of Total Billed Charges","neg_dollar:$21.80","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","23.00",""
"SUCRALFATE 1 G PO TABS","A9270","HCPCS","51079-753-01","NDC","637","RC","","Facility","Outpatient","1","GM","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","101% of Medicare Fee Schedule","","","","1.40","Fee Schedule","","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PREDNISOLONE ACETATE 1 % OP SUSP","A9270","HCPCS","60758-119-05","NDC","637","RC","","Facility","Outpatient","1","UN","58.90","58.90","","","","58.90","Fee Schedule","","","","","58.90","Fee Schedule","101% of Medicare Fee Schedule","","","","58.90","Fee Schedule","","30.62","52","","","Percent of Total Billed Charges","neg_dollar:$30.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","58.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","58.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","50.65","86","","","Percent of Total Billed Charges","neg_dollar:$50.65","41.23","70","","","Percent of Total Billed Charges","neg_dollar:$41.23","30.62","52","","","Percent of Total Billed Charges","neg_dollar:$30.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","34.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.60;102% of Medicaid interim rate","44.17","75","","","Percent of Total Billed Charges","neg_dollar:$44.17","50.65","86","","","Percent of Total Billed Charges","neg_dollar:$50.65","41.23","70","","","Percent of Total Billed Charges","neg_dollar:$41.23","33.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.57;103.5% of Medicaid interim rate","58.90","150","","","Percent of Total Billed Charges","neg_dollar:$91.06;150% of Medicaid interim rate","47.12","80","","","Percent of Total Billed Charges","neg_dollar:$47.12;Percent of Total Billed Charges","54.18","92","","","Percent of Total Billed Charges","neg_dollar:$54.18","30.62","52","","","Percent of Total Billed Charges","neg_dollar:$30.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","30.62","52","","","Percent of Total Billed Charges","neg_dollar:$30.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","30.00","58.00",""
"CLOTRIMAZOLE 1 % EX CREA","A9270","HCPCS","68001-475-47","NDC","637","RC","","Facility","Outpatient","1","UN","15.80","15.80","","","","15.80","Fee Schedule","","","","","15.80","Fee Schedule","101% of Medicare Fee Schedule","","","","15.80","Fee Schedule","","8.21","52","","","Percent of Total Billed Charges","neg_dollar:$8.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","15.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","15.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.58","86","","","Percent of Total Billed Charges","neg_dollar:$13.58","11.06","70","","","Percent of Total Billed Charges","neg_dollar:$11.06","8.21","52","","","Percent of Total Billed Charges","neg_dollar:$8.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.28;102% of Medicaid interim rate","11.85","75","","","Percent of Total Billed Charges","neg_dollar:$11.85","13.58","86","","","Percent of Total Billed Charges","neg_dollar:$13.58","11.06","70","","","Percent of Total Billed Charges","neg_dollar:$11.06","9.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$9;103.5% of Medicaid interim rate","15.80","150","","","Percent of Total Billed Charges","neg_dollar:$24.42;150% of Medicaid interim rate","12.64","80","","","Percent of Total Billed Charges","neg_dollar:$12.64;Percent of Total Billed Charges","14.53","92","","","Percent of Total Billed Charges","neg_dollar:$14.53","8.21","52","","","Percent of Total Billed Charges","neg_dollar:$8.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.21","52","","","Percent of Total Billed Charges","neg_dollar:$8.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","15.00",""
"DICLOFENAC SODIUM 1 % EX GEL","A9270","HCPCS","45802-953-01","NDC","637","RC","","Facility","Outpatient","1","UN","24.05","24.05","","","","24.05","Fee Schedule","","","","","24.05","Fee Schedule","101% of Medicare Fee Schedule","","","","24.05","Fee Schedule","","12.50","52","","","Percent of Total Billed Charges","neg_dollar:$12.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.68","86","","","Percent of Total Billed Charges","neg_dollar:$20.68","16.83","70","","","Percent of Total Billed Charges","neg_dollar:$16.83","12.50","52","","","Percent of Total Billed Charges","neg_dollar:$12.50;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.12;102% of Medicaid interim rate","18.03","75","","","Percent of Total Billed Charges","neg_dollar:$18.03","20.68","86","","","Percent of Total Billed Charges","neg_dollar:$20.68","16.83","70","","","Percent of Total Billed Charges","neg_dollar:$16.83","13.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.70;103.5% of Medicaid interim rate","24.05","150","","","Percent of Total Billed Charges","neg_dollar:$37.18;150% of Medicaid interim rate","19.24","80","","","Percent of Total Billed Charges","neg_dollar:$19.24;Percent of Total Billed Charges","22.12","92","","","Percent of Total Billed Charges","neg_dollar:$22.12","12.50","52","","","Percent of Total Billed Charges","neg_dollar:$12.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.50","52","","","Percent of Total Billed Charges","neg_dollar:$12.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","24.00",""
"BUMETANIDE 1 MG PO TABS","A9270","HCPCS","69238-1490-1","NDC","250","RC","","Facility","Outpatient","1","ME","0.75","0.75","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","","","52","","0.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","","52","","0.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% of Medicaid interim rate","0.56","75","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;103.5% of Medicaid interim rate","0.75","150","","","Percent of Total Billed Charges","neg_dollar:$1.15;150% of Medicaid interim rate","0.60","80","","","Percent of Total Billed Charges","neg_dollar:$0.60;Percent of Total Billed Charges","0.69","92","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.75","Fee Schedule","","1.00","1.00",""
"ATROPINE SULFATE 1 % OP SOLN","A9270","HCPCS","60219-1748-2","NDC","637","RC","","Facility","Outpatient","1","UN","50","50.00","","","","50.00","Fee Schedule","","","","","50.00","Fee Schedule","101% of Medicare Fee Schedule","","","","50.00","Fee Schedule","","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","50.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","50.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","43.00","86","","","Percent of Total Billed Charges","neg_dollar:$43","35.00","70","","","Percent of Total Billed Charges","neg_dollar:$35","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;105% Medicare Outpatient Cost to Charge Ratio of 52%","29.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.37;102% of Medicaid interim rate","37.50","75","","","Percent of Total Billed Charges","neg_dollar:$37.50","43.00","86","","","Percent of Total Billed Charges","neg_dollar:$43","35.00","70","","","Percent of Total Billed Charges","neg_dollar:$35","28.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.49;103.5% of Medicaid interim rate","50.00","150","","","Percent of Total Billed Charges","neg_dollar:$77.30;150% of Medicaid interim rate","40.00","80","","","Percent of Total Billed Charges","neg_dollar:$40;Percent of Total Billed Charges","46.00","92","","","Percent of Total Billed Charges","neg_dollar:$46","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;100% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;100% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","50.00",""
"PREDNISOLONE ACETATE 1 % OP SUSP","A9270","HCPCS","61314-637-05","NDC","637","RC","","Facility","Outpatient","1","UN","59.20","59.20","","","","59.20","Fee Schedule","","","","","59.20","Fee Schedule","101% of Medicare Fee Schedule","","","","59.20","Fee Schedule","","30.78","52","","","Percent of Total Billed Charges","neg_dollar:$30.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","59.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","59.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","50.91","86","","","Percent of Total Billed Charges","neg_dollar:$50.91","41.44","70","","","Percent of Total Billed Charges","neg_dollar:$41.44","30.78","52","","","Percent of Total Billed Charges","neg_dollar:$30.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","34.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.77;102% of Medicaid interim rate","44.40","75","","","Percent of Total Billed Charges","neg_dollar:$44.40","50.91","86","","","Percent of Total Billed Charges","neg_dollar:$50.91","41.44","70","","","Percent of Total Billed Charges","neg_dollar:$41.44","33.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.74;103.5% of Medicaid interim rate","59.20","150","","","Percent of Total Billed Charges","neg_dollar:$91.52;150% of Medicaid interim rate","47.36","80","","","Percent of Total Billed Charges","neg_dollar:$47.36;Percent of Total Billed Charges","54.46","92","","","Percent of Total Billed Charges","neg_dollar:$54.46","30.78","52","","","Percent of Total Billed Charges","neg_dollar:$30.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","30.78","52","","","Percent of Total Billed Charges","neg_dollar:$30.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","30.00","59.00",""
"BUMETANIDE 1 MG PO TABS","A9270","HCPCS","69238-1490-1","NDC","637","RC","","Facility","Outpatient","1","ME","0.75","0.75","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","101% of Medicare Fee Schedule","","","","0.75","Fee Schedule","","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% of Medicaid interim rate","0.56","75","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;103.5% of Medicaid interim rate","0.75","150","","","Percent of Total Billed Charges","neg_dollar:$1.15;150% of Medicaid interim rate","0.60","80","","","Percent of Total Billed Charges","neg_dollar:$0.60;Percent of Total Billed Charges","0.69","92","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SODIUM CHLORIDE 1 G PO TABS","A9270","HCPCS","77333-844-25","NDC","637","RC","","Facility","Outpatient","1","GM","3.90","3.90","","","","3.90","Fee Schedule","","","","","3.90","Fee Schedule","101% of Medicare Fee Schedule","","","","3.90","Fee Schedule","","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.35","86","","","Percent of Total Billed Charges","neg_dollar:$3.35","2.73","70","","","Percent of Total Billed Charges","neg_dollar:$2.73","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.29;102% of Medicaid interim rate","2.92","75","","","Percent of Total Billed Charges","neg_dollar:$2.92","3.35","86","","","Percent of Total Billed Charges","neg_dollar:$3.35","2.73","70","","","Percent of Total Billed Charges","neg_dollar:$2.73","2.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.22;103.5% of Medicaid interim rate","3.90","150","","","Percent of Total Billed Charges","neg_dollar:$6.02;150% of Medicaid interim rate","3.12","80","","","Percent of Total Billed Charges","neg_dollar:$3.12;Percent of Total Billed Charges","3.58","92","","","Percent of Total Billed Charges","neg_dollar:$3.58","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","3.00",""
"DICLOFENAC SODIUM 1 % EX GEL","A9270","HCPCS","00067-8152-03","NDC","637","RC","","Facility","Outpatient","1","UN","25.50","25.50","","","","25.50","Fee Schedule","","","","","25.50","Fee Schedule","101% of Medicare Fee Schedule","","","","25.50","Fee Schedule","","13.26","52","","","Percent of Total Billed Charges","neg_dollar:$13.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","21.93","86","","","Percent of Total Billed Charges","neg_dollar:$21.93","17.84","70","","","Percent of Total Billed Charges","neg_dollar:$17.84","13.26","52","","","Percent of Total Billed Charges","neg_dollar:$13.26;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.98;102% of Medicaid interim rate","19.12","75","","","Percent of Total Billed Charges","neg_dollar:$19.12","21.93","86","","","Percent of Total Billed Charges","neg_dollar:$21.93","17.84","70","","","Percent of Total Billed Charges","neg_dollar:$17.84","14.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.53;103.5% of Medicaid interim rate","25.50","150","","","Percent of Total Billed Charges","neg_dollar:$39.42;150% of Medicaid interim rate","20.40","80","","","Percent of Total Billed Charges","neg_dollar:$20.40;Percent of Total Billed Charges","23.46","92","","","Percent of Total Billed Charges","neg_dollar:$23.46","13.26","52","","","Percent of Total Billed Charges","neg_dollar:$13.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.26","52","","","Percent of Total Billed Charges","neg_dollar:$13.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","25.00",""
"BUMETANIDE 1 MG PO TABS","A9270","HCPCS","50268-131-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.53","1.53","","","","1.53","Fee Schedule","","","","","1.53","Fee Schedule","101% of Medicare Fee Schedule","","","","1.53","Fee Schedule","","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.53","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.53","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.31","86","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.07","70","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.90;102% of Medicaid interim rate","1.14","75","","","Percent of Total Billed Charges","neg_dollar:$1.14","1.31","86","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.07","70","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.87;103.5% of Medicaid interim rate","1.53","150","","","Percent of Total Billed Charges","neg_dollar:$2.37;150% of Medicaid interim rate","1.22","80","","","Percent of Total Billed Charges","neg_dollar:$1.22;Percent of Total Billed Charges","1.41","92","","","Percent of Total Billed Charges","neg_dollar:$1.41","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"POLYVINYL ALCOHOL 1.4 % OP SOLN","A9270","HCPCS","00536-1408-94","NDC","250","RC","","Facility","Outpatient","1","UN","16.40","16.40","","","","16.40","Fee Schedule","","","","","16.40","Fee Schedule","","","","","16.40","Fee Schedule","","","52","","16.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.10","86","","","Percent of Total Billed Charges","neg_dollar:$14.10","11.47","70","","","Percent of Total Billed Charges","neg_dollar:$11.47","","52","","16.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.63;102% of Medicaid interim rate","12.29","75","","","Percent of Total Billed Charges","neg_dollar:$12.29","14.10","86","","","Percent of Total Billed Charges","neg_dollar:$14.10","11.47","70","","","Percent of Total Billed Charges","neg_dollar:$11.47","9.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.34;103.5% of Medicaid interim rate","16.40","150","","","Percent of Total Billed Charges","neg_dollar:$25.35;150% of Medicaid interim rate","13.12","80","","","Percent of Total Billed Charges","neg_dollar:$13.12;Percent of Total Billed Charges","15.08","92","","","Percent of Total Billed Charges","neg_dollar:$15.08","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","16.40","Fee Schedule","","8.00","16.00",""
"SCOPOLAMINE 1 MG/3DAYS TD PT72","A9270","HCPCS","45802-580-84","NDC","250","RC","","Facility","Outpatient","1","EA","20.30","20.30","","","","20.30","Fee Schedule","","","","","20.30","Fee Schedule","","","","","20.30","Fee Schedule","","","52","","20.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.55","52","","","Percent of Total Billed Charges","neg_dollar:$10.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.55","52","","","Percent of Total Billed Charges","neg_dollar:$10.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.45","86","","","Percent of Total Billed Charges","neg_dollar:$17.45","14.20","70","","","Percent of Total Billed Charges","neg_dollar:$14.20","","52","","20.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","11.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.92;102% of Medicaid interim rate","15.22","75","","","Percent of Total Billed Charges","neg_dollar:$15.22","17.45","86","","","Percent of Total Billed Charges","neg_dollar:$17.45","14.20","70","","","Percent of Total Billed Charges","neg_dollar:$14.20","11.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.57;103.5% of Medicaid interim rate","20.30","150","","","Percent of Total Billed Charges","neg_dollar:$31.38;150% of Medicaid interim rate","16.24","80","","","Percent of Total Billed Charges","neg_dollar:$16.24;Percent of Total Billed Charges","18.67","92","","","Percent of Total Billed Charges","neg_dollar:$18.67","10.55","52","","","Percent of Total Billed Charges","neg_dollar:$10.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","20.30","Fee Schedule","","10.00","20.00",""
"SCOPOLAMINE 1 MG/3DAYS TD PT72","A9270","HCPCS","45802-580-84","NDC","637","RC","","Facility","Outpatient","1","EA","20.30","20.30","","","","20.30","Fee Schedule","","","","","20.30","Fee Schedule","101% of Medicare Fee Schedule","","","","20.30","Fee Schedule","","10.55","52","","","Percent of Total Billed Charges","neg_dollar:$10.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.45","86","","","Percent of Total Billed Charges","neg_dollar:$17.45","14.20","70","","","Percent of Total Billed Charges","neg_dollar:$14.20","10.55","52","","","Percent of Total Billed Charges","neg_dollar:$10.55;105% Medicare Outpatient Cost to Charge Ratio of 52%","11.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.92;102% of Medicaid interim rate","15.22","75","","","Percent of Total Billed Charges","neg_dollar:$15.22","17.45","86","","","Percent of Total Billed Charges","neg_dollar:$17.45","14.20","70","","","Percent of Total Billed Charges","neg_dollar:$14.20","11.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.57;103.5% of Medicaid interim rate","20.30","150","","","Percent of Total Billed Charges","neg_dollar:$31.38;150% of Medicaid interim rate","16.24","80","","","Percent of Total Billed Charges","neg_dollar:$16.24;Percent of Total Billed Charges","18.67","92","","","Percent of Total Billed Charges","neg_dollar:$18.67","10.55","52","","","Percent of Total Billed Charges","neg_dollar:$10.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.55","52","","","Percent of Total Billed Charges","neg_dollar:$10.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.00","20.00",""
"MAGNESIUM CITRATE 1.745 GM/30ML PO SOLN","A9270","HCPCS","71399-7889-1","NDC","250","RC","","Facility","Outpatient","1","EA","4.60","4.60","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","","52","","4.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% of Medicaid interim rate","3.44","75","","","Percent of Total Billed Charges","neg_dollar:$3.44","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.62;103.5% of Medicaid interim rate","4.60","150","","","Percent of Total Billed Charges","neg_dollar:$7.11;150% of Medicaid interim rate","3.67","80","","","Percent of Total Billed Charges","neg_dollar:$3.67;Percent of Total Billed Charges","4.23","92","","","Percent of Total Billed Charges","neg_dollar:$4.23","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.60","Fee Schedule","","2.00","4.00",""
"MAGNESIUM CITRATE 1.745 GM/30ML PO SOLN","A9270","HCPCS","71399-7889-1","NDC","637","RC","","Facility","Outpatient","1","EA","4.60","4.60","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","101% of Medicare Fee Schedule","","","","4.60","Fee Schedule","","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% of Medicaid interim rate","3.44","75","","","Percent of Total Billed Charges","neg_dollar:$3.44","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.62;103.5% of Medicaid interim rate","4.60","150","","","Percent of Total Billed Charges","neg_dollar:$7.11;150% of Medicaid interim rate","3.67","80","","","Percent of Total Billed Charges","neg_dollar:$3.67;Percent of Total Billed Charges","4.23","92","","","Percent of Total Billed Charges","neg_dollar:$4.23","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"MAGNESIUM CITRATE 1.745 GM/30ML PO SOLN","A9270","HCPCS","69452-389-98","NDC","637","RC","","Facility","Outpatient","1","EA","1.92","1.92","","","","1.92","Fee Schedule","","","","","1.92","Fee Schedule","101% of Medicare Fee Schedule","","","","1.92","Fee Schedule","","1.00","52","","","Percent of Total Billed Charges","neg_dollar:$1;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.65","86","","","Percent of Total Billed Charges","neg_dollar:$1.65","1.34","70","","","Percent of Total Billed Charges","neg_dollar:$1.34","1.00","52","","","Percent of Total Billed Charges","neg_dollar:$1;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.13;102% of Medicaid interim rate","1.44","75","","","Percent of Total Billed Charges","neg_dollar:$1.44","1.65","86","","","Percent of Total Billed Charges","neg_dollar:$1.65","1.34","70","","","Percent of Total Billed Charges","neg_dollar:$1.34","1.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.09;103.5% of Medicaid interim rate","1.92","150","","","Percent of Total Billed Charges","neg_dollar:$2.97;150% of Medicaid interim rate","1.54","80","","","Percent of Total Billed Charges","neg_dollar:$1.54;Percent of Total Billed Charges","1.77","92","","","Percent of Total Billed Charges","neg_dollar:$1.77","1.00","52","","","Percent of Total Billed Charges","neg_dollar:$1;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","52","","","Percent of Total Billed Charges","neg_dollar:$1;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MAGNESIUM CITRATE 1.745 GM/30ML PO SOLN","A9270","HCPCS","71399-0051-1","NDC","637","RC","","Facility","Outpatient","1","EA","2.80","2.80","","","","2.80","Fee Schedule","","","","","2.80","Fee Schedule","101% of Medicare Fee Schedule","","","","2.80","Fee Schedule","","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.40","86","","","Percent of Total Billed Charges","neg_dollar:$2.40","1.95","70","","","Percent of Total Billed Charges","neg_dollar:$1.95","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.64;102% of Medicaid interim rate","2.09","75","","","Percent of Total Billed Charges","neg_dollar:$2.09","2.40","86","","","Percent of Total Billed Charges","neg_dollar:$2.40","1.95","70","","","Percent of Total Billed Charges","neg_dollar:$1.95","1.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.59;103.5% of Medicaid interim rate","2.80","150","","","Percent of Total Billed Charges","neg_dollar:$4.32;150% of Medicaid interim rate","2.23","80","","","Percent of Total Billed Charges","neg_dollar:$2.23;Percent of Total Billed Charges","2.57","92","","","Percent of Total Billed Charges","neg_dollar:$2.57","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"CETIRIZINE HCL 10 MG PO TABS","A9270","HCPCS","00904-6717-61","NDC","250","RC","","Facility","Outpatient","10","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"POTASSIUM CHLORIDE CRYS ER 10 MEQ PO TBCR","A9270","HCPCS","00245-5317-89","NDC","250","RC","","Facility","Outpatient","1","EA","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.79","75","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.63;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.97","92","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"BENAZEPRIL HCL 10 MG PO TABS","A9270","HCPCS","50268-110-15","NDC","250","RC","","Facility","Outpatient","10","ME","1.41","1.41","","","","1.41","Fee Schedule","","","","","1.41","Fee Schedule","","","","","1.41","Fee Schedule","","","52","","1.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.21","86","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.98","70","","","Percent of Total Billed Charges","neg_dollar:$0.98","","52","","1.41","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% of Medicaid interim rate","1.06","75","","","Percent of Total Billed Charges","neg_dollar:$1.06","1.21","86","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.98","70","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.80;103.5% of Medicaid interim rate","1.41","150","","","Percent of Total Billed Charges","neg_dollar:$2.18;150% of Medicaid interim rate","1.13","80","","","Percent of Total Billed Charges","neg_dollar:$1.13;Percent of Total Billed Charges","1.30","92","","","Percent of Total Billed Charges","neg_dollar:$1.30","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.41","Fee Schedule","","1.00","1.00",""
"EMPAGLIFLOZIN 10 MG PO TABS","A9270","HCPCS","00597-0152-37","NDC","250","RC","","Facility","Outpatient","10","ME","24.10","24.10","","","","24.10","Fee Schedule","","","","","24.10","Fee Schedule","","","","","24.10","Fee Schedule","","","52","","24.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.53","52","","","Percent of Total Billed Charges","neg_dollar:$12.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.53","52","","","Percent of Total Billed Charges","neg_dollar:$12.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.73","86","","","Percent of Total Billed Charges","neg_dollar:$20.73","16.87","70","","","Percent of Total Billed Charges","neg_dollar:$16.87","","52","","24.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.16;102% of Medicaid interim rate","18.07","75","","","Percent of Total Billed Charges","neg_dollar:$18.07","20.73","86","","","Percent of Total Billed Charges","neg_dollar:$20.73","16.87","70","","","Percent of Total Billed Charges","neg_dollar:$16.87","13.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.74;103.5% of Medicaid interim rate","24.10","150","","","Percent of Total Billed Charges","neg_dollar:$37.26;150% of Medicaid interim rate","19.28","80","","","Percent of Total Billed Charges","neg_dollar:$19.28;Percent of Total Billed Charges","22.17","92","","","Percent of Total Billed Charges","neg_dollar:$22.17","12.53","52","","","Percent of Total Billed Charges","neg_dollar:$12.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","24.10","Fee Schedule","","12.00","24.00",""
"BACLOFEN 10 MG PO TABS","A9270","HCPCS","50268-106-11","NDC","250","RC","","Facility","Outpatient","10","ME","1.65","1.65","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","","52","","1.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.23","75","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.65","150","","","Percent of Total Billed Charges","neg_dollar:$2.55;150% of Medicaid interim rate","1.32","80","","","Percent of Total Billed Charges","neg_dollar:$1.32;Percent of Total Billed Charges","1.51","92","","","Percent of Total Billed Charges","neg_dollar:$1.51","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.65","Fee Schedule","","1.00","1.00",""
"RIVAROXABAN 10 MG PO TABS","A9270","HCPCS","50458-580-30","NDC","250","RC","","Facility","Outpatient","10","ME","18.91","18.91","","","","18.91","Fee Schedule","","","","","18.91","Fee Schedule","","","","","18.91","Fee Schedule","","","52","","18.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.83","52","","","Percent of Total Billed Charges","neg_dollar:$9.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.83","52","","","Percent of Total Billed Charges","neg_dollar:$9.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.26","86","","","Percent of Total Billed Charges","neg_dollar:$16.26","13.23","70","","","Percent of Total Billed Charges","neg_dollar:$13.23","","52","","18.91","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","11.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.11;102% of Medicaid interim rate","14.18","75","","","Percent of Total Billed Charges","neg_dollar:$14.18","16.26","86","","","Percent of Total Billed Charges","neg_dollar:$16.26","13.23","70","","","Percent of Total Billed Charges","neg_dollar:$13.23","10.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.78;103.5% of Medicaid interim rate","18.91","150","","","Percent of Total Billed Charges","neg_dollar:$29.24;150% of Medicaid interim rate","15.13","80","","","Percent of Total Billed Charges","neg_dollar:$15.13;Percent of Total Billed Charges","17.40","92","","","Percent of Total Billed Charges","neg_dollar:$17.40","9.83","52","","","Percent of Total Billed Charges","neg_dollar:$9.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","18.91","Fee Schedule","","9.00","18.00",""
"SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK","A9270","HCPCS","00310-1110-39","NDC","250","RC","","Facility","Outpatient","10","GM","33.85","33.85","","","","33.85","Fee Schedule","","","","","33.85","Fee Schedule","","","","","33.85","Fee Schedule","","","52","","33.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.60","52","","","Percent of Total Billed Charges","neg_dollar:$17.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.60","52","","","Percent of Total Billed Charges","neg_dollar:$17.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","29.11","86","","","Percent of Total Billed Charges","neg_dollar:$29.11","23.69","70","","","Percent of Total Billed Charges","neg_dollar:$23.69","","52","","33.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","19.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.88;102% of Medicaid interim rate","25.38","75","","","Percent of Total Billed Charges","neg_dollar:$25.38","29.11","86","","","Percent of Total Billed Charges","neg_dollar:$29.11","23.69","70","","","Percent of Total Billed Charges","neg_dollar:$23.69","19.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.29;103.5% of Medicaid interim rate","33.85","150","","","Percent of Total Billed Charges","neg_dollar:$52.33;150% of Medicaid interim rate","27.08","80","","","Percent of Total Billed Charges","neg_dollar:$27.08;Percent of Total Billed Charges","31.14","92","","","Percent of Total Billed Charges","neg_dollar:$31.14","17.60","52","","","Percent of Total Billed Charges","neg_dollar:$17.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","33.85","Fee Schedule","","17.00","33.00",""
"BISACODYL 10 MG RE SUPP","A9270","HCPCS","00574-7050-12","NDC","250","RC","","Facility","Outpatient","10","ME","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","","52","","1.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.45","Fee Schedule","","1.00","1.00",""
"METOCLOPRAMIDE HCL 10 MG PO TABS","A9270","HCPCS","00093-2203-01","NDC","250","RC","","Facility","Outpatient","10","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"POTASSIUM CHLORIDE CRYS ER 10 MEQ PO TBCR","A9270","HCPCS","00245-5317-01","NDC","250","RC","","Facility","Outpatient","1","EA","1.26","1.26","","","","1.26","Fee Schedule","","","","","1.26","Fee Schedule","","","","","1.26","Fee Schedule","","","52","","1.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","86","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","70","","","Percent of Total Billed Charges","neg_dollar:$0.88","","52","","1.26","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;102% of Medicaid interim rate","0.94","75","","","Percent of Total Billed Charges","neg_dollar:$0.94","1.08","86","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","70","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.72;103.5% of Medicaid interim rate","1.26","150","","","Percent of Total Billed Charges","neg_dollar:$1.95;150% of Medicaid interim rate","1.01","80","","","Percent of Total Billed Charges","neg_dollar:$1.01;Percent of Total Billed Charges","1.16","92","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.26","Fee Schedule","","1.00","1.00",""
"SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK","A9270","HCPCS","00310-1110-01","NDC","250","RC","","Facility","Outpatient","10","GM","33.85","33.85","","","","33.85","Fee Schedule","","","","","33.85","Fee Schedule","","","","","33.85","Fee Schedule","","","52","","33.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.60","52","","","Percent of Total Billed Charges","neg_dollar:$17.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.60","52","","","Percent of Total Billed Charges","neg_dollar:$17.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","29.11","86","","","Percent of Total Billed Charges","neg_dollar:$29.11","23.69","70","","","Percent of Total Billed Charges","neg_dollar:$23.69","","52","","33.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","19.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.88;102% of Medicaid interim rate","25.38","75","","","Percent of Total Billed Charges","neg_dollar:$25.38","29.11","86","","","Percent of Total Billed Charges","neg_dollar:$29.11","23.69","70","","","Percent of Total Billed Charges","neg_dollar:$23.69","19.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.29;103.5% of Medicaid interim rate","33.85","150","","","Percent of Total Billed Charges","neg_dollar:$52.33;150% of Medicaid interim rate","27.08","80","","","Percent of Total Billed Charges","neg_dollar:$27.08;Percent of Total Billed Charges","31.14","92","","","Percent of Total Billed Charges","neg_dollar:$31.14","17.60","52","","","Percent of Total Billed Charges","neg_dollar:$17.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","33.85","Fee Schedule","","17.00","33.00",""
"HYDROXYZINE HCL 10 MG PO TABS","A9270","HCPCS","63739-483-10","NDC","250","RC","","Facility","Outpatient","10","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"ATORVASTATIN CALCIUM 10 MG PO TABS","A9270","HCPCS","68084-097-11","NDC","250","RC","","Facility","Outpatient","10","ME","0.96","0.96","","","","0.96","Fee Schedule","","","","","0.96","Fee Schedule","","","","","0.96","Fee Schedule","","","52","","0.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","86","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.67","70","","","Percent of Total Billed Charges","neg_dollar:$0.67","","52","","0.96","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% of Medicaid interim rate","0.72","75","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.83","86","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.67","70","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;103.5% of Medicaid interim rate","0.96","150","","","Percent of Total Billed Charges","neg_dollar:$1.49;150% of Medicaid interim rate","0.77","80","","","Percent of Total Billed Charges","neg_dollar:$0.77;Percent of Total Billed Charges","0.88","92","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.96","Fee Schedule","","1.00","1.00",""
"BISACODYL 10 MG RE SUPP","A9270","HCPCS","71399-8460-2","NDC","250","RC","","Facility","Outpatient","10","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"POTASSIUM CHLORIDE CRYS ER 10 MEQ PO TBCR","A9270","HCPCS","00245-5317-01","NDC","637","RC","","Facility","Outpatient","1","EA","1.26","1.26","","","","1.26","Fee Schedule","","","","","1.26","Fee Schedule","101% of Medicare Fee Schedule","","","","1.26","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","86","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","70","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;102% of Medicaid interim rate","0.94","75","","","Percent of Total Billed Charges","neg_dollar:$0.94","1.08","86","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","70","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.72;103.5% of Medicaid interim rate","1.26","150","","","Percent of Total Billed Charges","neg_dollar:$1.95;150% of Medicaid interim rate","1.01","80","","","Percent of Total Billed Charges","neg_dollar:$1.01;Percent of Total Billed Charges","1.16","92","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"POTASSIUM CHLORIDE CRYS ER 10 MEQ PO TBCR","A9270","HCPCS","00245-5317-89","NDC","637","RC","","Facility","Outpatient","1","EA","1.03","1.03","","","","1.03","Fee Schedule","","","","","1.03","Fee Schedule","101% of Medicare Fee Schedule","","","","1.03","Fee Schedule","","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","86","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% of Medicaid interim rate","0.77","75","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.88","86","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;103.5% of Medicaid interim rate","1.03","150","","","Percent of Total Billed Charges","neg_dollar:$1.59;150% of Medicaid interim rate","0.82","80","","","Percent of Total Billed Charges","neg_dollar:$0.82;Percent of Total Billed Charges","0.95","92","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"UREA 10 % EX CREA","A9270","HCPCS","58980-605-30","NDC","250","RC","","Facility","Outpatient","1","EA","18.75","18.75","","","","18.75","Fee Schedule","","","","","18.75","Fee Schedule","","","","","18.75","Fee Schedule","","","52","","18.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.75","52","","","Percent of Total Billed Charges","neg_dollar:$9.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.75","52","","","Percent of Total Billed Charges","neg_dollar:$9.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.12","86","","","Percent of Total Billed Charges","neg_dollar:$16.12","13.12","70","","","Percent of Total Billed Charges","neg_dollar:$13.12","","52","","18.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","11.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.01;102% of Medicaid interim rate","14.06","75","","","Percent of Total Billed Charges","neg_dollar:$14.06","16.12","86","","","Percent of Total Billed Charges","neg_dollar:$16.12","13.12","70","","","Percent of Total Billed Charges","neg_dollar:$13.12","10.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.68;103.5% of Medicaid interim rate","18.75","150","","","Percent of Total Billed Charges","neg_dollar:$28.98;150% of Medicaid interim rate","15.00","80","","","Percent of Total Billed Charges","neg_dollar:$15;Percent of Total Billed Charges","17.25","92","","","Percent of Total Billed Charges","neg_dollar:$17.25","9.75","52","","","Percent of Total Billed Charges","neg_dollar:$9.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","18.75","Fee Schedule","","9.00","18.00",""
"OXYCODONE HCL ER 10 MG PO T12A","A9270","HCPCS","59011-410-20","NDC","250","RC","","Facility","Outpatient","10","ME","7.07","7.07","","","","7.07","Fee Schedule","","","","","7.07","Fee Schedule","","","","","7.07","Fee Schedule","","","52","","7.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.67","52","","","Percent of Total Billed Charges","neg_dollar:$3.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.67","52","","","Percent of Total Billed Charges","neg_dollar:$3.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.08","86","","","Percent of Total Billed Charges","neg_dollar:$6.08","4.95","70","","","Percent of Total Billed Charges","neg_dollar:$4.95","","52","","7.07","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","4.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.15;102% of Medicaid interim rate","5.30","75","","","Percent of Total Billed Charges","neg_dollar:$5.30","6.08","86","","","Percent of Total Billed Charges","neg_dollar:$6.08","4.95","70","","","Percent of Total Billed Charges","neg_dollar:$4.95","4.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.03;103.5% of Medicaid interim rate","7.07","150","","","Percent of Total Billed Charges","neg_dollar:$10.93;150% of Medicaid interim rate","5.66","80","","","Percent of Total Billed Charges","neg_dollar:$5.66;Percent of Total Billed Charges","6.50","92","","","Percent of Total Billed Charges","neg_dollar:$6.50","3.67","52","","","Percent of Total Billed Charges","neg_dollar:$3.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","7.07","Fee Schedule","","3.00","7.00",""
"ATORVASTATIN CALCIUM 10 MG PO TABS","A9270","HCPCS","68084-097-01","NDC","250","RC","","Facility","Outpatient","10","ME","0.95","0.95","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","","52","","0.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.71","75","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;103.5% of Medicaid interim rate","0.95","150","","","Percent of Total Billed Charges","neg_dollar:$1.46;150% of Medicaid interim rate","0.76","80","","","Percent of Total Billed Charges","neg_dollar:$0.76;Percent of Total Billed Charges","0.87","92","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.95","Fee Schedule","","1.00","1.00",""
"CETIRIZINE HCL 10 MG PO TABS","A9270","HCPCS","00904-6717-61","NDC","637","RC","","Facility","Outpatient","10","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BENAZEPRIL HCL 10 MG PO TABS","A9270","HCPCS","65862-116-01","NDC","250","RC","","Facility","Outpatient","10","ME","0.43","0.43","","","","0.43","Fee Schedule","","","","","0.43","Fee Schedule","","","","","0.43","Fee Schedule","","","52","","0.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.22","52","","","Percent of Total Billed Charges","neg_dollar:$0.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.22","52","","","Percent of Total Billed Charges","neg_dollar:$0.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","86","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.30","70","","","Percent of Total Billed Charges","neg_dollar:$0.30","","52","","0.43","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.25;102% of Medicaid interim rate","0.32","75","","","Percent of Total Billed Charges","neg_dollar:$0.32","0.37","86","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.30","70","","","Percent of Total Billed Charges","neg_dollar:$0.30","0.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.24;103.5% of Medicaid interim rate","0.43","150","","","Percent of Total Billed Charges","neg_dollar:$0.67;150% of Medicaid interim rate","0.34","80","","","Percent of Total Billed Charges","neg_dollar:$0.34;Percent of Total Billed Charges","0.39","92","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.22","52","","","Percent of Total Billed Charges","neg_dollar:$0.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.43","Fee Schedule","","1.00","1.00",""
"ESCITALOPRAM OXALATE 10 MG PO TABS","A9270","HCPCS","68084-617-01","NDC","250","RC","","Facility","Outpatient","10","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"MONTELUKAST SODIUM 10 MG PO TABS","A9270","HCPCS","68084-875-11","NDC","250","RC","","Facility","Outpatient","10","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"BACLOFEN 10 MG PO TABS","A9270","HCPCS","70710-1285-1","NDC","250","RC","","Facility","Outpatient","10","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"BISACODYL 10 MG RE SUPP","A9270","HCPCS","00574-7050-12","NDC","637","RC","","Facility","Outpatient","10","ME","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","101% of Medicare Fee Schedule","","","","1.45","Fee Schedule","","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ARIPIPRAZOLE 10 MG PO TABS","A9270","HCPCS","13668-218-30","NDC","637","RC","","Facility","Outpatient","10","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BACLOFEN 10 MG PO TABS","A9270","HCPCS","50268-106-15","NDC","637","RC","","Facility","Outpatient","10","ME","1.65","1.65","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","101% of Medicare Fee Schedule","","","","1.65","Fee Schedule","","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.23","75","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.65","150","","","Percent of Total Billed Charges","neg_dollar:$2.55;150% of Medicaid interim rate","1.32","80","","","Percent of Total Billed Charges","neg_dollar:$1.32;Percent of Total Billed Charges","1.51","92","","","Percent of Total Billed Charges","neg_dollar:$1.51","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ROSUVASTATIN CALCIUM 10 MG PO TABS","A9270","HCPCS","60687-245-11","NDC","250","RC","","Facility","Outpatient","10","ME","2.19","2.19","","","","2.19","Fee Schedule","","","","","2.19","Fee Schedule","","","","","2.19","Fee Schedule","","","52","","2.19","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","52","","","Percent of Total Billed Charges","neg_dollar:$1.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","52","","","Percent of Total Billed Charges","neg_dollar:$1.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.88","86","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.53","70","","","Percent of Total Billed Charges","neg_dollar:$1.53","","52","","2.19","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.29;102% of Medicaid interim rate","1.64","75","","","Percent of Total Billed Charges","neg_dollar:$1.64","1.88","86","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.53","70","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.25;103.5% of Medicaid interim rate","2.19","150","","","Percent of Total Billed Charges","neg_dollar:$3.39;150% of Medicaid interim rate","1.75","80","","","Percent of Total Billed Charges","neg_dollar:$1.75;Percent of Total Billed Charges","2.02","92","","","Percent of Total Billed Charges","neg_dollar:$2.02","1.14","52","","","Percent of Total Billed Charges","neg_dollar:$1.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.19","Fee Schedule","","1.00","2.00",""
"LACTULOSE 10 GM/15ML PO SOLN","A9270","HCPCS","00121-1154-00","NDC","250","RC","","Facility","Outpatient","1","UN","2.10","2.10","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","","52","","2.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% of Medicaid interim rate","1.57","75","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.19;103.5% of Medicaid interim rate","2.10","150","","","Percent of Total Billed Charges","neg_dollar:$3.24;150% of Medicaid interim rate","1.68","80","","","Percent of Total Billed Charges","neg_dollar:$1.68;Percent of Total Billed Charges","1.93","92","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.10","Fee Schedule","","1.00","2.00",""
"DONEPEZIL HCL 10 MG PO TABS","A9270","HCPCS","60687-303-11","NDC","250","RC","","Facility","Outpatient","10","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"CYCLOBENZAPRINE HCL 10 MG PO TABS","A9270","HCPCS","60687-558-01","NDC","250","RC","","Facility","Outpatient","10","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"PROPRANOLOL HCL 10 MG PO TABS","A9270","HCPCS","60687-587-11","NDC","250","RC","","Facility","Outpatient","10","ME","0.80","0.80","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","","","52","","0.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","","52","","0.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.60","75","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.80","150","","","Percent of Total Billed Charges","neg_dollar:$1.23;150% of Medicaid interim rate","0.64","80","","","Percent of Total Billed Charges","neg_dollar:$0.64;Percent of Total Billed Charges","0.73","92","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.80","Fee Schedule","","1.00","1.00",""
"CYCLOBENZAPRINE HCL 10 MG PO TABS","A9270","HCPCS","60687-558-11","NDC","250","RC","","Facility","Outpatient","10","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"LORATADINE 10 MG PO TABS","A9270","HCPCS","68084-248-11","NDC","250","RC","","Facility","Outpatient","10","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"ESCITALOPRAM OXALATE 10 MG PO TABS","A9270","HCPCS","68084-617-11","NDC","250","RC","","Facility","Outpatient","10","ME","1","1.00","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","","52","","1.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% of Medicaid interim rate","0.75","75","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.00","150","","","Percent of Total Billed Charges","neg_dollar:$1.55;150% of Medicaid interim rate","0.80","80","","","Percent of Total Billed Charges","neg_dollar:$0.80;Percent of Total Billed Charges","0.92","92","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.00","Fee Schedule","","1.00","1.00",""
"NORTRIPTYLINE HCL 10 MG PO CAPS","A9270","HCPCS","50268-603-11","NDC","637","RC","","Facility","Outpatient","10","ME","0.81","0.81","","","","0.81","Fee Schedule","","","","","0.81","Fee Schedule","101% of Medicare Fee Schedule","","","","0.81","Fee Schedule","","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","86","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% of Medicaid interim rate","0.61","75","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.70","86","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;103.5% of Medicaid interim rate","0.81","150","","","Percent of Total Billed Charges","neg_dollar:$1.26;150% of Medicaid interim rate","0.65","80","","","Percent of Total Billed Charges","neg_dollar:$0.65;Percent of Total Billed Charges","0.75","92","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DONEPEZIL HCL 10 MG PO TABS","A9270","HCPCS","60687-303-01","NDC","637","RC","","Facility","Outpatient","10","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HYDROXYZINE HCL 10 MG PO TABS","A9270","HCPCS","63739-483-10","NDC","637","RC","","Facility","Outpatient","10","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LORATADINE 10 MG PO TABS","A9270","HCPCS","68084-248-11","NDC","637","RC","","Facility","Outpatient","10","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","101% of Medicare Fee Schedule","","","","1.35","Fee Schedule","","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BENAZEPRIL HCL 10 MG PO TABS","A9270","HCPCS","65862-116-01","NDC","637","RC","","Facility","Outpatient","10","ME","0.52","0.52","","","","0.52","Fee Schedule","","","","","0.52","Fee Schedule","101% of Medicare Fee Schedule","","","","0.52","Fee Schedule","","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.52","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.52","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","86","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.36","70","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.30;102% of Medicaid interim rate","0.39","75","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.44","86","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.36","70","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;103.5% of Medicaid interim rate","0.52","150","","","Percent of Total Billed Charges","neg_dollar:$0.80;150% of Medicaid interim rate","0.41","80","","","Percent of Total Billed Charges","neg_dollar:$0.41;Percent of Total Billed Charges","0.47","92","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MONTELUKAST SODIUM 10 MG PO TABS","A9270","HCPCS","68084-875-11","NDC","637","RC","","Facility","Outpatient","10","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","101% of Medicare Fee Schedule","","","","1.60","Fee Schedule","","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BENAZEPRIL HCL 10 MG PO TABS","A9270","HCPCS","50268-110-15","NDC","637","RC","","Facility","Outpatient","10","ME","1.51","1.51","","","","1.51","Fee Schedule","","","","","1.51","Fee Schedule","101% of Medicare Fee Schedule","","","","1.51","Fee Schedule","","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","86","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.06","70","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.89;102% of Medicaid interim rate","1.13","75","","","Percent of Total Billed Charges","neg_dollar:$1.13","1.30","86","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.06","70","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.86;103.5% of Medicaid interim rate","1.51","150","","","Percent of Total Billed Charges","neg_dollar:$2.34;150% of Medicaid interim rate","1.21","80","","","Percent of Total Billed Charges","neg_dollar:$1.21;Percent of Total Billed Charges","1.39","92","","","Percent of Total Billed Charges","neg_dollar:$1.39","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CYCLOBENZAPRINE HCL 10 MG PO TABS","A9270","HCPCS","60687-558-11","NDC","637","RC","","Facility","Outpatient","10","ME","1.38","1.38","","","","1.38","Fee Schedule","","","","","1.38","Fee Schedule","101% of Medicare Fee Schedule","","","","1.38","Fee Schedule","","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.19","86","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","70","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.81;102% of Medicaid interim rate","1.03","75","","","Percent of Total Billed Charges","neg_dollar:$1.03","1.19","86","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","70","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.78;103.5% of Medicaid interim rate","1.38","150","","","Percent of Total Billed Charges","neg_dollar:$2.14;150% of Medicaid interim rate","1.10","80","","","Percent of Total Billed Charges","neg_dollar:$1.10;Percent of Total Billed Charges","1.27","92","","","Percent of Total Billed Charges","neg_dollar:$1.27","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"RIVAROXABAN 10 MG PO TABS","A9270","HCPCS","50458-580-30","NDC","637","RC","","Facility","Outpatient","10","ME","21.25","21.25","","","","21.25","Fee Schedule","","","","","21.25","Fee Schedule","101% of Medicare Fee Schedule","","","","21.25","Fee Schedule","","11.05","52","","","Percent of Total Billed Charges","neg_dollar:$11.05;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","21.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","21.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","18.28","86","","","Percent of Total Billed Charges","neg_dollar:$18.28","14.88","70","","","Percent of Total Billed Charges","neg_dollar:$14.88","11.05","52","","","Percent of Total Billed Charges","neg_dollar:$11.05;105% Medicare Outpatient Cost to Charge Ratio of 52%","12.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.48;102% of Medicaid interim rate","15.94","75","","","Percent of Total Billed Charges","neg_dollar:$15.94","18.28","86","","","Percent of Total Billed Charges","neg_dollar:$18.28","14.88","70","","","Percent of Total Billed Charges","neg_dollar:$14.88","12.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.11;103.5% of Medicaid interim rate","21.25","150","","","Percent of Total Billed Charges","neg_dollar:$32.86;150% of Medicaid interim rate","17.00","80","","","Percent of Total Billed Charges","neg_dollar:$17;Percent of Total Billed Charges","19.55","92","","","Percent of Total Billed Charges","neg_dollar:$19.55","11.05","52","","","Percent of Total Billed Charges","neg_dollar:$11.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.05","52","","","Percent of Total Billed Charges","neg_dollar:$11.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.00","21.00",""
"METOCLOPRAMIDE HCL 10 MG PO TABS","A9270","HCPCS","00093-2203-01","NDC","637","RC","","Facility","Outpatient","10","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK","A9270","HCPCS","00310-1110-01","NDC","637","RC","","Facility","Outpatient","10","GM","33.85","33.85","","","","33.85","Fee Schedule","","","","","33.85","Fee Schedule","101% of Medicare Fee Schedule","","","","33.85","Fee Schedule","","17.60","52","","","Percent of Total Billed Charges","neg_dollar:$17.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","33.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","33.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","29.11","86","","","Percent of Total Billed Charges","neg_dollar:$29.11","23.69","70","","","Percent of Total Billed Charges","neg_dollar:$23.69","17.60","52","","","Percent of Total Billed Charges","neg_dollar:$17.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.88;102% of Medicaid interim rate","25.38","75","","","Percent of Total Billed Charges","neg_dollar:$25.38","29.11","86","","","Percent of Total Billed Charges","neg_dollar:$29.11","23.69","70","","","Percent of Total Billed Charges","neg_dollar:$23.69","19.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.29;103.5% of Medicaid interim rate","33.85","150","","","Percent of Total Billed Charges","neg_dollar:$52.33;150% of Medicaid interim rate","27.08","80","","","Percent of Total Billed Charges","neg_dollar:$27.08;Percent of Total Billed Charges","31.14","92","","","Percent of Total Billed Charges","neg_dollar:$31.14","17.60","52","","","Percent of Total Billed Charges","neg_dollar:$17.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.60","52","","","Percent of Total Billed Charges","neg_dollar:$17.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","33.00",""
"EMPAGLIFLOZIN 10 MG PO TABS","A9270","HCPCS","00597-0152-37","NDC","637","RC","","Facility","Outpatient","10","ME","23.57","23.57","","","","23.57","Fee Schedule","","","","","23.57","Fee Schedule","101% of Medicare Fee Schedule","","","","23.57","Fee Schedule","","12.25","52","","","Percent of Total Billed Charges","neg_dollar:$12.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.27","86","","","Percent of Total Billed Charges","neg_dollar:$20.27","16.50","70","","","Percent of Total Billed Charges","neg_dollar:$16.50","12.25","52","","","Percent of Total Billed Charges","neg_dollar:$12.25;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.85;102% of Medicaid interim rate","17.68","75","","","Percent of Total Billed Charges","neg_dollar:$17.68","20.27","86","","","Percent of Total Billed Charges","neg_dollar:$20.27","16.50","70","","","Percent of Total Billed Charges","neg_dollar:$16.50","13.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.43;103.5% of Medicaid interim rate","23.57","150","","","Percent of Total Billed Charges","neg_dollar:$36.44;150% of Medicaid interim rate","18.86","80","","","Percent of Total Billed Charges","neg_dollar:$18.86;Percent of Total Billed Charges","21.68","92","","","Percent of Total Billed Charges","neg_dollar:$21.68","12.25","52","","","Percent of Total Billed Charges","neg_dollar:$12.25;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.25","52","","","Percent of Total Billed Charges","neg_dollar:$12.25;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","23.00",""
"BACLOFEN 10 MG PO TABS","A9270","HCPCS","50268-106-11","NDC","637","RC","","Facility","Outpatient","10","ME","1.65","1.65","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","101% of Medicare Fee Schedule","","","","1.65","Fee Schedule","","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.23","75","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.65","150","","","Percent of Total Billed Charges","neg_dollar:$2.55;150% of Medicaid interim rate","1.32","80","","","Percent of Total Billed Charges","neg_dollar:$1.32;Percent of Total Billed Charges","1.51","92","","","Percent of Total Billed Charges","neg_dollar:$1.51","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ESCITALOPRAM OXALATE 10 MG PO TABS","A9270","HCPCS","68084-617-11","NDC","637","RC","","Facility","Outpatient","10","ME","0.81","0.81","","","","0.81","Fee Schedule","","","","","0.81","Fee Schedule","101% of Medicare Fee Schedule","","","","0.81","Fee Schedule","","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","86","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","70","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% of Medicaid interim rate","0.60","75","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.69","86","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","70","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;103.5% of Medicaid interim rate","0.81","150","","","Percent of Total Billed Charges","neg_dollar:$1.25;150% of Medicaid interim rate","0.64","80","","","Percent of Total Billed Charges","neg_dollar:$0.64;Percent of Total Billed Charges","0.74","92","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ROSUVASTATIN CALCIUM 10 MG PO TABS","A9270","HCPCS","60687-245-11","NDC","637","RC","","Facility","Outpatient","10","ME","2.30","2.30","","","","2.30","Fee Schedule","","","","","2.30","Fee Schedule","101% of Medicare Fee Schedule","","","","2.30","Fee Schedule","","1.20","52","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.98","86","","","Percent of Total Billed Charges","neg_dollar:$1.98","1.61","70","","","Percent of Total Billed Charges","neg_dollar:$1.61","1.20","52","","","Percent of Total Billed Charges","neg_dollar:$1.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% of Medicaid interim rate","1.73","75","","","Percent of Total Billed Charges","neg_dollar:$1.73","1.98","86","","","Percent of Total Billed Charges","neg_dollar:$1.98","1.61","70","","","Percent of Total Billed Charges","neg_dollar:$1.61","1.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.31;103.5% of Medicaid interim rate","2.30","150","","","Percent of Total Billed Charges","neg_dollar:$3.56;150% of Medicaid interim rate","1.84","80","","","Percent of Total Billed Charges","neg_dollar:$1.84;Percent of Total Billed Charges","2.12","92","","","Percent of Total Billed Charges","neg_dollar:$2.12","1.20","52","","","Percent of Total Billed Charges","neg_dollar:$1.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","52","","","Percent of Total Billed Charges","neg_dollar:$1.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"DONEPEZIL HCL 10 MG PO TABS","A9270","HCPCS","60687-303-11","NDC","637","RC","","Facility","Outpatient","10","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PROPRANOLOL HCL 10 MG PO TABS","A9270","HCPCS","60687-587-11","NDC","637","RC","","Facility","Outpatient","10","ME","0.46","0.46","","","","0.46","Fee Schedule","","","","","0.46","Fee Schedule","101% of Medicare Fee Schedule","","","","0.46","Fee Schedule","","0.24","52","","","Percent of Total Billed Charges","neg_dollar:$0.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.46","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.46","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","86","","","Percent of Total Billed Charges","neg_dollar:$0.40","0.32","70","","","Percent of Total Billed Charges","neg_dollar:$0.32","0.24","52","","","Percent of Total Billed Charges","neg_dollar:$0.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.27;102% of Medicaid interim rate","0.34","75","","","Percent of Total Billed Charges","neg_dollar:$0.34","0.40","86","","","Percent of Total Billed Charges","neg_dollar:$0.40","0.32","70","","","Percent of Total Billed Charges","neg_dollar:$0.32","0.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.26;103.5% of Medicaid interim rate","0.46","150","","","Percent of Total Billed Charges","neg_dollar:$0.72;150% of Medicaid interim rate","0.37","80","","","Percent of Total Billed Charges","neg_dollar:$0.37;Percent of Total Billed Charges","0.42","92","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.24","52","","","Percent of Total Billed Charges","neg_dollar:$0.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.24","52","","","Percent of Total Billed Charges","neg_dollar:$0.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BACLOFEN 10 MG PO TABS","A9270","HCPCS","70710-1285-1","NDC","637","RC","","Facility","Outpatient","10","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LORATADINE 10 MG PO TABS","A9270","HCPCS","68084-248-01","NDC","637","RC","","Facility","Outpatient","10","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","101% of Medicare Fee Schedule","","","","1.35","Fee Schedule","","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LACTULOSE 10 GM/15ML PO SOLN","A9270","HCPCS","00121-1154-00","NDC","637","RC","","Facility","Outpatient","1","UN","3.20","3.20","","","","3.20","Fee Schedule","","","","","3.20","Fee Schedule","101% of Medicare Fee Schedule","","","","3.20","Fee Schedule","","1.66","52","","","Percent of Total Billed Charges","neg_dollar:$1.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.75","86","","","Percent of Total Billed Charges","neg_dollar:$2.75","2.23","70","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.66","52","","","Percent of Total Billed Charges","neg_dollar:$1.66;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.87;102% of Medicaid interim rate","2.40","75","","","Percent of Total Billed Charges","neg_dollar:$2.40","2.75","86","","","Percent of Total Billed Charges","neg_dollar:$2.75","2.23","70","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.82;103.5% of Medicaid interim rate","3.20","150","","","Percent of Total Billed Charges","neg_dollar:$4.94;150% of Medicaid interim rate","2.56","80","","","Percent of Total Billed Charges","neg_dollar:$2.56;Percent of Total Billed Charges","2.94","92","","","Percent of Total Billed Charges","neg_dollar:$2.94","1.66","52","","","Percent of Total Billed Charges","neg_dollar:$1.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.66","52","","","Percent of Total Billed Charges","neg_dollar:$1.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"ATORVASTATIN CALCIUM 10 MG PO TABS","A9270","HCPCS","68084-097-11","NDC","637","RC","","Facility","Outpatient","1","EA","1.09","1.09","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","101% of Medicare Fee Schedule","","","","1.09","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.09","150","","","Percent of Total Billed Charges","neg_dollar:$1.69;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TAKE HOME CYCLOBENZAPRINE 10 MG TABS (QTY:SIX)","A9270","HCPCS","60687-558-01","NDC","250","RC","","Facility","Outpatient","1","EA","10.90","10.90","","","","10.90","Fee Schedule","","","","","10.90","Fee Schedule","","","","","10.90","Fee Schedule","","","52","","10.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.66","52","","","Percent of Total Billed Charges","neg_dollar:$5.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.66","52","","","Percent of Total Billed Charges","neg_dollar:$5.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.37","86","","","Percent of Total Billed Charges","neg_dollar:$9.37","7.63","70","","","Percent of Total Billed Charges","neg_dollar:$7.63","","52","","10.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.40;102% of Medicaid interim rate","8.17","75","","","Percent of Total Billed Charges","neg_dollar:$8.17","9.37","86","","","Percent of Total Billed Charges","neg_dollar:$9.37","7.63","70","","","Percent of Total Billed Charges","neg_dollar:$7.63","6.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.21;103.5% of Medicaid interim rate","10.90","150","","","Percent of Total Billed Charges","neg_dollar:$16.85;150% of Medicaid interim rate","8.72","80","","","Percent of Total Billed Charges","neg_dollar:$8.72;Percent of Total Billed Charges","10.02","92","","","Percent of Total Billed Charges","neg_dollar:$10.02","5.66","52","","","Percent of Total Billed Charges","neg_dollar:$5.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.90","Fee Schedule","","5.00","10.00",""
"TAKE HOME CYCLOBENZAPRINE 10 MG TABS (QTY:SIX)","A9270","HCPCS","60687-558-01","NDC","253","RC","","Facility","Outpatient","1","EA","10.90","10.90","10.90","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","5.66","52","","","Percent of Total Billed Charges","neg_dollar:$5.66;101% Medicare Outpatient Cost to Charge Ratio of 52%","10.90","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","5.66","52","","","Percent of Total Billed Charges","neg_dollar:$5.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.66","52","","","Percent of Total Billed Charges","neg_dollar:$5.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.66","52","","","Percent of Total Billed Charges","neg_dollar:$5.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.37","86","","","Percent of Total Billed Charges","neg_dollar:$9.37","7.63","70","","","Percent of Total Billed Charges","neg_dollar:$7.63","5.66","52","","","Percent of Total Billed Charges","neg_dollar:$5.66;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.40;102% of Medicaid interim rate","8.17","75","","","Percent of Total Billed Charges","neg_dollar:$8.17","9.37","86","","","Percent of Total Billed Charges","neg_dollar:$9.37","7.63","70","","","Percent of Total Billed Charges","neg_dollar:$7.63","6.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.21;103.5% of Medicaid interim rate","10.90","150","","","Percent of Total Billed Charges","neg_dollar:$16.85;150% of Medicaid interim rate","8.72","80","","","Percent of Total Billed Charges","neg_dollar:$8.72;Percent of Total Billed Charges","10.02","92","","","Percent of Total Billed Charges","neg_dollar:$10.02","5.66","52","","","Percent of Total Billed Charges","neg_dollar:$5.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.66","52","","","Percent of Total Billed Charges","neg_dollar:$5.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA","A9270","HCPCS","00168-0258-46","NDC","250","RC","","Facility","Outpatient","1","EA","50.45","50.45","","","","50.45","Fee Schedule","","","","","50.45","Fee Schedule","","","","","50.45","Fee Schedule","","","52","","50.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","26.23","52","","","Percent of Total Billed Charges","neg_dollar:$26.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.23","52","","","Percent of Total Billed Charges","neg_dollar:$26.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","43.38","86","","","Percent of Total Billed Charges","neg_dollar:$43.38","35.31","70","","","Percent of Total Billed Charges","neg_dollar:$35.31","","52","","50.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","29.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.63;102% of Medicaid interim rate","37.83","75","","","Percent of Total Billed Charges","neg_dollar:$37.83","43.38","86","","","Percent of Total Billed Charges","neg_dollar:$43.38","35.31","70","","","Percent of Total Billed Charges","neg_dollar:$35.31","28.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.75;103.5% of Medicaid interim rate","50.45","150","","","Percent of Total Billed Charges","neg_dollar:$77.99;150% of Medicaid interim rate","40.36","80","","","Percent of Total Billed Charges","neg_dollar:$40.36;Percent of Total Billed Charges","46.41","92","","","Percent of Total Billed Charges","neg_dollar:$46.41","26.23","52","","","Percent of Total Billed Charges","neg_dollar:$26.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","50.45","Fee Schedule","","26.00","50.00",""
"CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA","A9270","HCPCS","00168-0258-46","NDC","637","RC","","Facility","Outpatient","1","EA","50.45","50.45","","","","50.45","Fee Schedule","","","","","50.45","Fee Schedule","101% of Medicare Fee Schedule","","","","50.45","Fee Schedule","","26.23","52","","","Percent of Total Billed Charges","neg_dollar:$26.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","50.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","50.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","43.38","86","","","Percent of Total Billed Charges","neg_dollar:$43.38","35.31","70","","","Percent of Total Billed Charges","neg_dollar:$35.31","26.23","52","","","Percent of Total Billed Charges","neg_dollar:$26.23;105% Medicare Outpatient Cost to Charge Ratio of 52%","29.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.63;102% of Medicaid interim rate","37.83","75","","","Percent of Total Billed Charges","neg_dollar:$37.83","43.38","86","","","Percent of Total Billed Charges","neg_dollar:$43.38","35.31","70","","","Percent of Total Billed Charges","neg_dollar:$35.31","28.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.75;103.5% of Medicaid interim rate","50.45","150","","","Percent of Total Billed Charges","neg_dollar:$77.99;150% of Medicaid interim rate","40.36","80","","","Percent of Total Billed Charges","neg_dollar:$40.36;Percent of Total Billed Charges","46.41","92","","","Percent of Total Billed Charges","neg_dollar:$46.41","26.23","52","","","Percent of Total Billed Charges","neg_dollar:$26.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","26.23","52","","","Percent of Total Billed Charges","neg_dollar:$26.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","50.00",""
"FLUCONAZOLE 100 MG PO TABS","A9270","HCPCS","50268-337-11","NDC","250","RC","","Facility","Outpatient","100","ME","2.72","2.72","","","","2.72","Fee Schedule","","","","","2.72","Fee Schedule","","","","","2.72","Fee Schedule","","","52","","2.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","52","","","Percent of Total Billed Charges","neg_dollar:$1.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","52","","","Percent of Total Billed Charges","neg_dollar:$1.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.34","86","","","Percent of Total Billed Charges","neg_dollar:$2.34","1.91","70","","","Percent of Total Billed Charges","neg_dollar:$1.91","","52","","2.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.60;102% of Medicaid interim rate","2.04","75","","","Percent of Total Billed Charges","neg_dollar:$2.04","2.34","86","","","Percent of Total Billed Charges","neg_dollar:$2.34","1.91","70","","","Percent of Total Billed Charges","neg_dollar:$1.91","1.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.55;103.5% of Medicaid interim rate","2.72","150","","","Percent of Total Billed Charges","neg_dollar:$4.21;150% of Medicaid interim rate","2.18","80","","","Percent of Total Billed Charges","neg_dollar:$2.18;Percent of Total Billed Charges","2.51","92","","","Percent of Total Billed Charges","neg_dollar:$2.51","1.41","52","","","Percent of Total Billed Charges","neg_dollar:$1.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.72","Fee Schedule","","1.00","2.00",""
"DOCUSATE SODIUM 100 MG PO CAPS","A9270","HCPCS","00904-7183-61","NDC","250","RC","","Facility","Outpatient","100","ME","1.04","1.04","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","52","","1.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.04","150","","","Percent of Total Billed Charges","neg_dollar:$1.61;150% of Medicaid interim rate","0.83","80","","","Percent of Total Billed Charges","neg_dollar:$0.83;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.04","Fee Schedule","","1.00","1.00",""
"TAPENTADOL HCL ER 100 MG PO TB12","A9270","HCPCS","24510-116-60","NDC","250","RC","","Facility","Outpatient","100","ME","25.60","25.60","","","","25.60","Fee Schedule","","","","","25.60","Fee Schedule","","","","","25.60","Fee Schedule","","","52","","25.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.31","52","","","Percent of Total Billed Charges","neg_dollar:$13.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.31","52","","","Percent of Total Billed Charges","neg_dollar:$13.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","22.01","86","","","Percent of Total Billed Charges","neg_dollar:$22.01","17.91","70","","","Percent of Total Billed Charges","neg_dollar:$17.91","","52","","25.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","15.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.03;102% of Medicaid interim rate","19.20","75","","","Percent of Total Billed Charges","neg_dollar:$19.20","22.01","86","","","Percent of Total Billed Charges","neg_dollar:$22.01","17.91","70","","","Percent of Total Billed Charges","neg_dollar:$17.91","14.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.59;103.5% of Medicaid interim rate","25.60","150","","","Percent of Total Billed Charges","neg_dollar:$39.57;150% of Medicaid interim rate","20.48","80","","","Percent of Total Billed Charges","neg_dollar:$20.48;Percent of Total Billed Charges","23.55","92","","","Percent of Total Billed Charges","neg_dollar:$23.55","13.31","52","","","Percent of Total Billed Charges","neg_dollar:$13.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.60","Fee Schedule","","13.00","25.00",""
"CELECOXIB 100 MG PO CAPS","A9270","HCPCS","60687-436-01","NDC","250","RC","","Facility","Outpatient","100","ME","2.25","2.25","","","","2.25","Fee Schedule","","","","","2.25","Fee Schedule","","","","","2.25","Fee Schedule","","","52","","2.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.93","86","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","","52","","2.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% of Medicaid interim rate","1.68","75","","","Percent of Total Billed Charges","neg_dollar:$1.68","1.93","86","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.28;103.5% of Medicaid interim rate","2.25","150","","","Percent of Total Billed Charges","neg_dollar:$3.47;150% of Medicaid interim rate","1.80","80","","","Percent of Total Billed Charges","neg_dollar:$1.80;Percent of Total Billed Charges","2.07","92","","","Percent of Total Billed Charges","neg_dollar:$2.07","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.25","Fee Schedule","","1.00","2.00",""
"GUAIFENESIN 100 MG/5ML PO LIQD","A9270","HCPCS","00536-1314-85","NDC","250","RC","","Facility","Outpatient","5","ML","10.60","10.60","","","","10.60","Fee Schedule","","","","","10.60","Fee Schedule","","","","","10.60","Fee Schedule","","","52","","10.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.51","52","","","Percent of Total Billed Charges","neg_dollar:$5.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.51","52","","","Percent of Total Billed Charges","neg_dollar:$5.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.11","86","","","Percent of Total Billed Charges","neg_dollar:$9.11","7.41","70","","","Percent of Total Billed Charges","neg_dollar:$7.41","","52","","10.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.22;102% of Medicaid interim rate","7.94","75","","","Percent of Total Billed Charges","neg_dollar:$7.94","9.11","86","","","Percent of Total Billed Charges","neg_dollar:$9.11","7.41","70","","","Percent of Total Billed Charges","neg_dollar:$7.41","6.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.04;103.5% of Medicaid interim rate","10.60","150","","","Percent of Total Billed Charges","neg_dollar:$16.38;150% of Medicaid interim rate","8.48","80","","","Percent of Total Billed Charges","neg_dollar:$8.48;Percent of Total Billed Charges","9.75","92","","","Percent of Total Billed Charges","neg_dollar:$9.75","5.51","52","","","Percent of Total Billed Charges","neg_dollar:$5.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.60","Fee Schedule","","5.00","10.00",""
"METOPROLOL SUCCINATE ER 100 MG PO TB24","A9270","HCPCS","60687-413-11","NDC","250","RC","","Facility","Outpatient","100","ME","2.70","2.70","","","","2.70","Fee Schedule","","","","","2.70","Fee Schedule","","","","","2.70","Fee Schedule","","","52","","2.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.32","86","","","Percent of Total Billed Charges","neg_dollar:$2.32","1.89","70","","","Percent of Total Billed Charges","neg_dollar:$1.89","","52","","2.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.58;102% of Medicaid interim rate","2.02","75","","","Percent of Total Billed Charges","neg_dollar:$2.02","2.32","86","","","Percent of Total Billed Charges","neg_dollar:$2.32","1.89","70","","","Percent of Total Billed Charges","neg_dollar:$1.89","1.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.53;103.5% of Medicaid interim rate","2.70","150","","","Percent of Total Billed Charges","neg_dollar:$4.17;150% of Medicaid interim rate","2.16","80","","","Percent of Total Billed Charges","neg_dollar:$2.16;Percent of Total Billed Charges","2.48","92","","","Percent of Total Billed Charges","neg_dollar:$2.48","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.70","Fee Schedule","","1.00","2.00",""
"GABAPENTIN 100 MG PO CAPS","A9270","HCPCS","60687-580-01","NDC","250","RC","","Facility","Outpatient","100","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","","52","","1.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.15","Fee Schedule","","1.00","1.00",""
"DOCUSATE SODIUM 100 MG PO CAPS","A9270","HCPCS","00904-7183-61","NDC","637","RC","","Facility","Outpatient","100","ME","0.96","0.96","","","","0.96","Fee Schedule","","","","","0.96","Fee Schedule","101% of Medicare Fee Schedule","","","","0.96","Fee Schedule","","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","86","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.67","70","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% of Medicaid interim rate","0.72","75","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.82","86","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.67","70","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;103.5% of Medicaid interim rate","0.96","150","","","Percent of Total Billed Charges","neg_dollar:$1.49;150% of Medicaid interim rate","0.77","80","","","Percent of Total Billed Charges","neg_dollar:$0.77;Percent of Total Billed Charges","0.88","92","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"GABAPENTIN 100 MG PO CAPS","A9270","HCPCS","60687-580-11","NDC","250","RC","","Facility","Outpatient","100","ME","0.80","0.80","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","","","52","","0.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.56","70","","","Percent of Total Billed Charges","neg_dollar:$0.56","","52","","0.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% of Medicaid interim rate","0.60","75","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.56","70","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.80","150","","","Percent of Total Billed Charges","neg_dollar:$1.23;150% of Medicaid interim rate","0.64","80","","","Percent of Total Billed Charges","neg_dollar:$0.64;Percent of Total Billed Charges","0.73","92","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.80","Fee Schedule","","1.00","1.00",""
"NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS","A9270","HCPCS","60687-633-11","NDC","250","RC","","Facility","Outpatient","100","ME","4.55","4.55","","","","4.55","Fee Schedule","","","","","4.55","Fee Schedule","","","","","4.55","Fee Schedule","","","52","","4.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.36","52","","","Percent of Total Billed Charges","neg_dollar:$2.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.36","52","","","Percent of Total Billed Charges","neg_dollar:$2.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.91","86","","","Percent of Total Billed Charges","neg_dollar:$3.91","3.18","70","","","Percent of Total Billed Charges","neg_dollar:$3.18","","52","","4.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.67;102% of Medicaid interim rate","3.41","75","","","Percent of Total Billed Charges","neg_dollar:$3.41","3.91","86","","","Percent of Total Billed Charges","neg_dollar:$3.91","3.18","70","","","Percent of Total Billed Charges","neg_dollar:$3.18","2.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.59;103.5% of Medicaid interim rate","4.55","150","","","Percent of Total Billed Charges","neg_dollar:$7.03;150% of Medicaid interim rate","3.64","80","","","Percent of Total Billed Charges","neg_dollar:$3.64;Percent of Total Billed Charges","4.18","92","","","Percent of Total Billed Charges","neg_dollar:$4.18","2.36","52","","","Percent of Total Billed Charges","neg_dollar:$2.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.55","Fee Schedule","","2.00","4.00",""
"DOXYCYCLINE HYCLATE 100 MG PO TABS","A9270","HCPCS","62584-693-21","NDC","250","RC","","Facility","Outpatient","100","ME","5.60","5.60","","","","5.60","Fee Schedule","","","","","5.60","Fee Schedule","","","","","5.60","Fee Schedule","","","52","","5.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.91","52","","","Percent of Total Billed Charges","neg_dollar:$2.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.91","52","","","Percent of Total Billed Charges","neg_dollar:$2.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.81","86","","","Percent of Total Billed Charges","neg_dollar:$4.81","3.91","70","","","Percent of Total Billed Charges","neg_dollar:$3.91","","52","","5.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.28;102% of Medicaid interim rate","4.19","75","","","Percent of Total Billed Charges","neg_dollar:$4.19","4.81","86","","","Percent of Total Billed Charges","neg_dollar:$4.81","3.91","70","","","Percent of Total Billed Charges","neg_dollar:$3.91","3.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.19;103.5% of Medicaid interim rate","5.60","150","","","Percent of Total Billed Charges","neg_dollar:$8.65;150% of Medicaid interim rate","4.47","80","","","Percent of Total Billed Charges","neg_dollar:$4.47;Percent of Total Billed Charges","5.15","92","","","Percent of Total Billed Charges","neg_dollar:$5.15","2.91","52","","","Percent of Total Billed Charges","neg_dollar:$2.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.60","Fee Schedule","","2.00","5.00",""
"BENZONATATE 100 MG PO CAPS","A9270","HCPCS","68084-214-11","NDC","250","RC","","Facility","Outpatient","100","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"GABAPENTIN 100 MG PO CAPS","A9270","HCPCS","00904-6665-61","NDC","637","RC","","Facility","Outpatient","100","ME","0.98","0.98","","","","0.98","Fee Schedule","","","","","0.98","Fee Schedule","101% of Medicare Fee Schedule","","","","0.98","Fee Schedule","","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.84","86","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","70","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% of Medicaid interim rate","0.73","75","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.84","86","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","70","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;103.5% of Medicaid interim rate","0.98","150","","","Percent of Total Billed Charges","neg_dollar:$1.52;150% of Medicaid interim rate","0.78","80","","","Percent of Total Billed Charges","neg_dollar:$0.78;Percent of Total Billed Charges","0.90","92","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LEVOTHYROXINE SODIUM 100 MCG PO TABS","A9270","HCPCS","60687-497-11","NDC","250","RC","","Facility","Outpatient","100","EA","1.09","1.09","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","","52","","1.09","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.09","150","","","Percent of Total Billed Charges","neg_dollar:$1.69;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.09","Fee Schedule","","1.00","1.00",""
"LAMOTRIGINE 100 MG PO TABS","A9270","HCPCS","68084-319-11","NDC","250","RC","","Facility","Outpatient","100","ME","0.75","0.75","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","","","52","","0.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","","52","","0.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% of Medicaid interim rate","0.56","75","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;103.5% of Medicaid interim rate","0.75","150","","","Percent of Total Billed Charges","neg_dollar:$1.15;150% of Medicaid interim rate","0.60","80","","","Percent of Total Billed Charges","neg_dollar:$0.60;Percent of Total Billed Charges","0.69","92","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.75","Fee Schedule","","1.00","1.00",""
"BUPROPION HCL 100 MG PO TABS","A9270","HCPCS","50268-143-11","NDC","637","RC","","Facility","Outpatient","100","ME","3.15","3.15","","","","3.15","Fee Schedule","","","","","3.15","Fee Schedule","101% of Medicare Fee Schedule","","","","3.15","Fee Schedule","","1.63","52","","","Percent of Total Billed Charges","neg_dollar:$1.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","86","","","Percent of Total Billed Charges","neg_dollar:$2.70","2.20","70","","","Percent of Total Billed Charges","neg_dollar:$2.20","1.63","52","","","Percent of Total Billed Charges","neg_dollar:$1.63;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.85;102% of Medicaid interim rate","2.36","75","","","Percent of Total Billed Charges","neg_dollar:$2.36","2.70","86","","","Percent of Total Billed Charges","neg_dollar:$2.70","2.20","70","","","Percent of Total Billed Charges","neg_dollar:$2.20","1.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.79;103.5% of Medicaid interim rate","3.15","150","","","Percent of Total Billed Charges","neg_dollar:$4.87;150% of Medicaid interim rate","2.52","80","","","Percent of Total Billed Charges","neg_dollar:$2.52;Percent of Total Billed Charges","2.89","92","","","Percent of Total Billed Charges","neg_dollar:$2.89","1.63","52","","","Percent of Total Billed Charges","neg_dollar:$1.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.63","52","","","Percent of Total Billed Charges","neg_dollar:$1.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"GABAPENTIN 100 MG PO CAPS","A9270","HCPCS","00904-6665-61","NDC","250","RC","","Facility","Outpatient","100","ME","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","","52","","0.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% of Medicaid interim rate","0.63","75","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.31;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.85","Fee Schedule","","1.00","1.00",""
"BUPROPION HCL 100 MG PO TABS","A9270","HCPCS","50268-143-11","NDC","250","RC","","Facility","Outpatient","100","ME","2.58","2.58","","","","2.58","Fee Schedule","","","","","2.58","Fee Schedule","","","","","2.58","Fee Schedule","","","52","","2.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.34","52","","","Percent of Total Billed Charges","neg_dollar:$1.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.34","52","","","Percent of Total Billed Charges","neg_dollar:$1.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.22","86","","","Percent of Total Billed Charges","neg_dollar:$2.22","1.80","70","","","Percent of Total Billed Charges","neg_dollar:$1.80","","52","","2.58","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.51;102% of Medicaid interim rate","1.93","75","","","Percent of Total Billed Charges","neg_dollar:$1.93","2.22","86","","","Percent of Total Billed Charges","neg_dollar:$2.22","1.80","70","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.47;103.5% of Medicaid interim rate","2.58","150","","","Percent of Total Billed Charges","neg_dollar:$3.99;150% of Medicaid interim rate","2.06","80","","","Percent of Total Billed Charges","neg_dollar:$2.06;Percent of Total Billed Charges","2.37","92","","","Percent of Total Billed Charges","neg_dollar:$2.37","1.34","52","","","Percent of Total Billed Charges","neg_dollar:$1.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.58","Fee Schedule","","1.00","2.00",""
"QUETIAPINE FUMARATE 100 MG PO TABS","A9270","HCPCS","60687-349-11","NDC","250","RC","","Facility","Outpatient","100","ME","1.33","1.33","","","","1.33","Fee Schedule","","","","","1.33","Fee Schedule","","","","","1.33","Fee Schedule","","","52","","1.33","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","86","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.93","70","","","Percent of Total Billed Charges","neg_dollar:$0.93","","52","","1.33","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% of Medicaid interim rate","0.99","75","","","Percent of Total Billed Charges","neg_dollar:$0.99","1.14","86","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.93","70","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.75;103.5% of Medicaid interim rate","1.33","150","","","Percent of Total Billed Charges","neg_dollar:$2.05;150% of Medicaid interim rate","1.06","80","","","Percent of Total Billed Charges","neg_dollar:$1.06;Percent of Total Billed Charges","1.22","92","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.33","Fee Schedule","","1.00","1.00",""
"LEVOTHYROXINE SODIUM 100 MCG PO TABS","A9270","HCPCS","60687-497-01","NDC","250","RC","","Facility","Outpatient","100","EA","1.22","1.22","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","","","52","","1.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","","52","","1.22","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% of Medicaid interim rate","0.91","75","","","Percent of Total Billed Charges","neg_dollar:$0.91","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;103.5% of Medicaid interim rate","1.22","150","","","Percent of Total Billed Charges","neg_dollar:$1.89;150% of Medicaid interim rate","0.98","80","","","Percent of Total Billed Charges","neg_dollar:$0.98;Percent of Total Billed Charges","1.12","92","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.22","Fee Schedule","","1.00","1.00",""
"ALLOPURINOL 100 MG PO TABS","A9270","HCPCS","60687-677-11","NDC","250","RC","","Facility","Outpatient","100","ME","1.21","1.21","","","","1.21","Fee Schedule","","","","","1.21","Fee Schedule","","","","","1.21","Fee Schedule","","","52","","1.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","86","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","","52","","1.21","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% of Medicaid interim rate","0.91","75","","","Percent of Total Billed Charges","neg_dollar:$0.91","1.04","86","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;103.5% of Medicaid interim rate","1.21","150","","","Percent of Total Billed Charges","neg_dollar:$1.88;150% of Medicaid interim rate","0.97","80","","","Percent of Total Billed Charges","neg_dollar:$0.97;Percent of Total Billed Charges","1.12","92","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.21","Fee Schedule","","1.00","1.00",""
"THIAMINE 100 MG TABLET WRAPPER","A9270","HCPCS","77333-934-25","NDC","250","RC","","Facility","Outpatient","100","EA","2.60","2.60","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","52","","2.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","","52","","2.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.52;102% of Medicaid interim rate","1.95","75","","","Percent of Total Billed Charges","neg_dollar:$1.95","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","1.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.48;103.5% of Medicaid interim rate","2.60","150","","","Percent of Total Billed Charges","neg_dollar:$4.01;150% of Medicaid interim rate","2.08","80","","","Percent of Total Billed Charges","neg_dollar:$2.08;Percent of Total Billed Charges","2.39","92","","","Percent of Total Billed Charges","neg_dollar:$2.39","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.60","Fee Schedule","","1.00","2.00",""
"CELECOXIB 100 MG PO CAPS","A9270","HCPCS","60687-436-11","NDC","250","RC","","Facility","Outpatient","100","ME","2.25","2.25","","","","2.25","Fee Schedule","","","","","2.25","Fee Schedule","","","","","2.25","Fee Schedule","","","52","","2.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.93","86","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","","52","","2.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% of Medicaid interim rate","1.68","75","","","Percent of Total Billed Charges","neg_dollar:$1.68","1.93","86","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.28;103.5% of Medicaid interim rate","2.25","150","","","Percent of Total Billed Charges","neg_dollar:$3.47;150% of Medicaid interim rate","1.80","80","","","Percent of Total Billed Charges","neg_dollar:$1.80;Percent of Total Billed Charges","2.07","92","","","Percent of Total Billed Charges","neg_dollar:$2.07","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.25","Fee Schedule","","1.00","2.00",""
"DOXYCYCLINE HYCLATE 100 MG PO TABS","A9270","HCPCS","62584-693-11","NDC","250","RC","","Facility","Outpatient","100","ME","5.60","5.60","","","","5.60","Fee Schedule","","","","","5.60","Fee Schedule","","","","","5.60","Fee Schedule","","","52","","5.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.91","52","","","Percent of Total Billed Charges","neg_dollar:$2.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.91","52","","","Percent of Total Billed Charges","neg_dollar:$2.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.81","86","","","Percent of Total Billed Charges","neg_dollar:$4.81","3.91","70","","","Percent of Total Billed Charges","neg_dollar:$3.91","","52","","5.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.28;102% of Medicaid interim rate","4.19","75","","","Percent of Total Billed Charges","neg_dollar:$4.19","4.81","86","","","Percent of Total Billed Charges","neg_dollar:$4.81","3.91","70","","","Percent of Total Billed Charges","neg_dollar:$3.91","3.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.19;103.5% of Medicaid interim rate","5.60","150","","","Percent of Total Billed Charges","neg_dollar:$8.65;150% of Medicaid interim rate","4.47","80","","","Percent of Total Billed Charges","neg_dollar:$4.47;Percent of Total Billed Charges","5.15","92","","","Percent of Total Billed Charges","neg_dollar:$5.15","2.91","52","","","Percent of Total Billed Charges","neg_dollar:$2.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.60","Fee Schedule","","2.00","5.00",""
"THIAMINE 100 MG TABLET WRAPPER","A9270","HCPCS","87701-40729","NDC","250","RC","","Facility","Outpatient","1","EA","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"GUAIFENESIN 100 MG/5ML PO LIQD","A9270","HCPCS","00121-1744-10","NDC","637","RC","","Facility","Outpatient","5","ML","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","101% of Medicare Fee Schedule","","","","1.55","Fee Schedule","","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"QUETIAPINE FUMARATE 100 MG PO TABS","A9270","HCPCS","60687-349-11","NDC","637","RC","","Facility","Outpatient","100","ME","1.16","1.16","","","","1.16","Fee Schedule","","","","","1.16","Fee Schedule","101% of Medicare Fee Schedule","","","","1.16","Fee Schedule","","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","86","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% of Medicaid interim rate","0.87","75","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.99","86","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.66;103.5% of Medicaid interim rate","1.16","150","","","Percent of Total Billed Charges","neg_dollar:$1.79;150% of Medicaid interim rate","0.92","80","","","Percent of Total Billed Charges","neg_dollar:$0.92;Percent of Total Billed Charges","1.06","92","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DOXYCYCLINE HYCLATE 100 MG PO TABS","A9270","HCPCS","62584-693-11","NDC","637","RC","","Facility","Outpatient","100","ME","5.45","5.45","","","","5.45","Fee Schedule","","","","","5.45","Fee Schedule","101% of Medicare Fee Schedule","","","","5.45","Fee Schedule","","2.83","52","","","Percent of Total Billed Charges","neg_dollar:$2.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.69","86","","","Percent of Total Billed Charges","neg_dollar:$4.69","3.81","70","","","Percent of Total Billed Charges","neg_dollar:$3.81","2.83","52","","","Percent of Total Billed Charges","neg_dollar:$2.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","3.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.20;102% of Medicaid interim rate","4.09","75","","","Percent of Total Billed Charges","neg_dollar:$4.09","4.69","86","","","Percent of Total Billed Charges","neg_dollar:$4.69","3.81","70","","","Percent of Total Billed Charges","neg_dollar:$3.81","3.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.11;103.5% of Medicaid interim rate","5.45","150","","","Percent of Total Billed Charges","neg_dollar:$8.43;150% of Medicaid interim rate","4.36","80","","","Percent of Total Billed Charges","neg_dollar:$4.36;Percent of Total Billed Charges","5.01","92","","","Percent of Total Billed Charges","neg_dollar:$5.01","2.83","52","","","Percent of Total Billed Charges","neg_dollar:$2.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.83","52","","","Percent of Total Billed Charges","neg_dollar:$2.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"BENZONATATE 100 MG PO CAPS","A9270","HCPCS","68084-214-01","NDC","637","RC","","Facility","Outpatient","100","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","101% of Medicare Fee Schedule","","","","1.60","Fee Schedule","","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS","A9270","HCPCS","00185-0122-01","NDC","637","RC","","Facility","Outpatient","100","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","101% of Medicare Fee Schedule","","","","1.60","Fee Schedule","","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS","A9270","HCPCS","60687-633-11","NDC","637","RC","","Facility","Outpatient","100","ME","4.55","4.55","","","","4.55","Fee Schedule","","","","","4.55","Fee Schedule","101% of Medicare Fee Schedule","","","","4.55","Fee Schedule","","2.36","52","","","Percent of Total Billed Charges","neg_dollar:$2.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.91","86","","","Percent of Total Billed Charges","neg_dollar:$3.91","3.18","70","","","Percent of Total Billed Charges","neg_dollar:$3.18","2.36","52","","","Percent of Total Billed Charges","neg_dollar:$2.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.67;102% of Medicaid interim rate","3.41","75","","","Percent of Total Billed Charges","neg_dollar:$3.41","3.91","86","","","Percent of Total Billed Charges","neg_dollar:$3.91","3.18","70","","","Percent of Total Billed Charges","neg_dollar:$3.18","2.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.59;103.5% of Medicaid interim rate","4.55","150","","","Percent of Total Billed Charges","neg_dollar:$7.03;150% of Medicaid interim rate","3.64","80","","","Percent of Total Billed Charges","neg_dollar:$3.64;Percent of Total Billed Charges","4.18","92","","","Percent of Total Billed Charges","neg_dollar:$4.18","2.36","52","","","Percent of Total Billed Charges","neg_dollar:$2.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.36","52","","","Percent of Total Billed Charges","neg_dollar:$2.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"DOXYCYCLINE HYCLATE 100 MG PO TABS","A9270","HCPCS","62584-693-21","NDC","637","RC","","Facility","Outpatient","100","ME","5.60","5.60","","","","5.60","Fee Schedule","","","","","5.60","Fee Schedule","101% of Medicare Fee Schedule","","","","5.60","Fee Schedule","","2.91","52","","","Percent of Total Billed Charges","neg_dollar:$2.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.81","86","","","Percent of Total Billed Charges","neg_dollar:$4.81","3.91","70","","","Percent of Total Billed Charges","neg_dollar:$3.91","2.91","52","","","Percent of Total Billed Charges","neg_dollar:$2.91;105% Medicare Outpatient Cost to Charge Ratio of 52%","3.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.28;102% of Medicaid interim rate","4.19","75","","","Percent of Total Billed Charges","neg_dollar:$4.19","4.81","86","","","Percent of Total Billed Charges","neg_dollar:$4.81","3.91","70","","","Percent of Total Billed Charges","neg_dollar:$3.91","3.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.19;103.5% of Medicaid interim rate","5.60","150","","","Percent of Total Billed Charges","neg_dollar:$8.65;150% of Medicaid interim rate","4.47","80","","","Percent of Total Billed Charges","neg_dollar:$4.47;Percent of Total Billed Charges","5.15","92","","","Percent of Total Billed Charges","neg_dollar:$5.15","2.91","52","","","Percent of Total Billed Charges","neg_dollar:$2.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.91","52","","","Percent of Total Billed Charges","neg_dollar:$2.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"METOPROLOL SUCCINATE ER 100 MG PO TB24","A9270","HCPCS","60687-413-11","NDC","637","RC","","Facility","Outpatient","100","ME","2.70","2.70","","","","2.70","Fee Schedule","","","","","2.70","Fee Schedule","101% of Medicare Fee Schedule","","","","2.70","Fee Schedule","","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.32","86","","","Percent of Total Billed Charges","neg_dollar:$2.32","1.89","70","","","Percent of Total Billed Charges","neg_dollar:$1.89","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.58;102% of Medicaid interim rate","2.02","75","","","Percent of Total Billed Charges","neg_dollar:$2.02","2.32","86","","","Percent of Total Billed Charges","neg_dollar:$2.32","1.89","70","","","Percent of Total Billed Charges","neg_dollar:$1.89","1.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.53;103.5% of Medicaid interim rate","2.70","150","","","Percent of Total Billed Charges","neg_dollar:$4.17;150% of Medicaid interim rate","2.16","80","","","Percent of Total Billed Charges","neg_dollar:$2.16;Percent of Total Billed Charges","2.48","92","","","Percent of Total Billed Charges","neg_dollar:$2.48","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"GABAPENTIN 100 MG PO CAPS","A9270","HCPCS","60687-580-11","NDC","637","RC","","Facility","Outpatient","100","ME","0.90","0.90","","","","0.90","Fee Schedule","","","","","0.90","Fee Schedule","101% of Medicare Fee Schedule","","","","0.90","Fee Schedule","","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% of Medicaid interim rate","0.67","75","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.90","150","","","Percent of Total Billed Charges","neg_dollar:$1.39;150% of Medicaid interim rate","0.72","80","","","Percent of Total Billed Charges","neg_dollar:$0.72;Percent of Total Billed Charges","0.82","92","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CELECOXIB 100 MG PO CAPS","A9270","HCPCS","60687-436-11","NDC","637","RC","","Facility","Outpatient","100","ME","2.25","2.25","","","","2.25","Fee Schedule","","","","","2.25","Fee Schedule","101% of Medicare Fee Schedule","","","","2.25","Fee Schedule","","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.93","86","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% of Medicaid interim rate","1.68","75","","","Percent of Total Billed Charges","neg_dollar:$1.68","1.93","86","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.28;103.5% of Medicaid interim rate","2.25","150","","","Percent of Total Billed Charges","neg_dollar:$3.47;150% of Medicaid interim rate","1.80","80","","","Percent of Total Billed Charges","neg_dollar:$1.80;Percent of Total Billed Charges","2.07","92","","","Percent of Total Billed Charges","neg_dollar:$2.07","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"LABETALOL HCL 100 MG PO TABS","A9270","HCPCS","60687-439-11","NDC","637","RC","","Facility","Outpatient","100","ME","1.21","1.21","","","","1.21","Fee Schedule","","","","","1.21","Fee Schedule","101% of Medicare Fee Schedule","","","","1.21","Fee Schedule","","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","86","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% of Medicaid interim rate","0.91","75","","","Percent of Total Billed Charges","neg_dollar:$0.91","1.04","86","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;103.5% of Medicaid interim rate","1.21","150","","","Percent of Total Billed Charges","neg_dollar:$1.88;150% of Medicaid interim rate","0.97","80","","","Percent of Total Billed Charges","neg_dollar:$0.97;Percent of Total Billed Charges","1.11","92","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ALLOPURINOL 100 MG PO TABS","A9270","HCPCS","60687-677-11","NDC","637","RC","","Facility","Outpatient","100","ME","1.16","1.16","","","","1.16","Fee Schedule","","","","","1.16","Fee Schedule","101% of Medicare Fee Schedule","","","","1.16","Fee Schedule","","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","86","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.99","86","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.66;103.5% of Medicaid interim rate","1.16","150","","","Percent of Total Billed Charges","neg_dollar:$1.79;150% of Medicaid interim rate","0.92","80","","","Percent of Total Billed Charges","neg_dollar:$0.92;Percent of Total Billed Charges","1.06","92","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BENZONATATE 100 MG PO CAPS","A9270","HCPCS","68084-214-11","NDC","637","RC","","Facility","Outpatient","100","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","101% of Medicare Fee Schedule","","","","1.60","Fee Schedule","","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FLUCONAZOLE 100 MG PO TABS","A9270","HCPCS","50268-337-11","NDC","637","RC","","Facility","Outpatient","100","ME","2.55","2.55","","","","2.55","Fee Schedule","","","","","2.55","Fee Schedule","101% of Medicare Fee Schedule","","","","2.55","Fee Schedule","","1.32","52","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.19","86","","","Percent of Total Billed Charges","neg_dollar:$2.19","1.78","70","","","Percent of Total Billed Charges","neg_dollar:$1.78","1.32","52","","","Percent of Total Billed Charges","neg_dollar:$1.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.49;102% of Medicaid interim rate","1.91","75","","","Percent of Total Billed Charges","neg_dollar:$1.91","2.19","86","","","Percent of Total Billed Charges","neg_dollar:$2.19","1.78","70","","","Percent of Total Billed Charges","neg_dollar:$1.78","1.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.45;103.5% of Medicaid interim rate","2.55","150","","","Percent of Total Billed Charges","neg_dollar:$3.94;150% of Medicaid interim rate","2.04","80","","","Percent of Total Billed Charges","neg_dollar:$2.04;Percent of Total Billed Charges","2.34","92","","","Percent of Total Billed Charges","neg_dollar:$2.34","1.32","52","","","Percent of Total Billed Charges","neg_dollar:$1.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","52","","","Percent of Total Billed Charges","neg_dollar:$1.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"LEVOTHYROXINE SODIUM 100 MCG PO TABS","A9270","HCPCS","60687-497-11","NDC","637","RC","","Facility","Outpatient","100","EA","1.61","1.61","","","","1.61","Fee Schedule","","","","","1.61","Fee Schedule","101% of Medicare Fee Schedule","","","","1.61","Fee Schedule","","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.12","70","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.12","70","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.61","150","","","Percent of Total Billed Charges","neg_dollar:$2.49;150% of Medicaid interim rate","1.29","80","","","Percent of Total Billed Charges","neg_dollar:$1.29;Percent of Total Billed Charges","1.48","92","","","Percent of Total Billed Charges","neg_dollar:$1.48","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LAMOTRIGINE 100 MG PO TABS","A9270","HCPCS","68084-319-11","NDC","637","RC","","Facility","Outpatient","100","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"GUAIFENESIN 100 MG/5ML PO LIQD","A9270","HCPCS","00536-1314-85","NDC","637","RC","","Facility","Outpatient","5","ML","10.60","10.60","","","","10.60","Fee Schedule","","","","","10.60","Fee Schedule","101% of Medicare Fee Schedule","","","","10.60","Fee Schedule","","5.51","52","","","Percent of Total Billed Charges","neg_dollar:$5.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.11","86","","","Percent of Total Billed Charges","neg_dollar:$9.11","7.41","70","","","Percent of Total Billed Charges","neg_dollar:$7.41","5.51","52","","","Percent of Total Billed Charges","neg_dollar:$5.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.22;102% of Medicaid interim rate","7.94","75","","","Percent of Total Billed Charges","neg_dollar:$7.94","9.11","86","","","Percent of Total Billed Charges","neg_dollar:$9.11","7.41","70","","","Percent of Total Billed Charges","neg_dollar:$7.41","6.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.04;103.5% of Medicaid interim rate","10.60","150","","","Percent of Total Billed Charges","neg_dollar:$16.38;150% of Medicaid interim rate","8.48","80","","","Percent of Total Billed Charges","neg_dollar:$8.48;Percent of Total Billed Charges","9.75","92","","","Percent of Total Billed Charges","neg_dollar:$9.75","5.51","52","","","Percent of Total Billed Charges","neg_dollar:$5.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.51","52","","","Percent of Total Billed Charges","neg_dollar:$5.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","A9270","HCPCS","00002-0213-01","NDC","637","RC","","Facility","Outpatient","1","ML","0.25","0.25","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","101% of Medicare Fee Schedule","","","","0.25","Fee Schedule","","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% of Medicaid interim rate","0.18","75","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.25","150","","","Percent of Total Billed Charges","neg_dollar:$0.38;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","A9270","HCPCS","00002-8215-01","NDC","637","RC","","Facility","Outpatient","1","ML","0.77","0.77","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","101% of Medicare Fee Schedule","","","","0.77","Fee Schedule","","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.57","75","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.77","150","","","Percent of Total Billed Charges","neg_dollar:$1.19;150% of Medicaid interim rate","0.61","80","","","Percent of Total Billed Charges","neg_dollar:$0.61;Percent of Total Billed Charges","0.71","92","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN","A9270","HCPCS","00002-8215-01","NDC","250","RC","","Facility","Outpatient","1","ML","0.77","0.77","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","","52","","0.77","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.57","75","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.77","150","","","Percent of Total Billed Charges","neg_dollar:$1.19;150% of Medicaid interim rate","0.61","80","","","Percent of Total Billed Charges","neg_dollar:$0.61;Percent of Total Billed Charges","0.71","92","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.77","Fee Schedule","","1.00","1.00",""
"INSULIN GLARGINE 100 UNIT/ML SC SOPN","A9270","HCPCS","00002-7715-01","NDC","250","RC","","Facility","Outpatient","1","ML","104.95","104.95","","","","104.95","Fee Schedule","","","","","104.95","Fee Schedule","","","","","104.95","Fee Schedule","","","52","","104.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","54.57","52","","","Percent of Total Billed Charges","neg_dollar:$54.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","54.57","52","","","Percent of Total Billed Charges","neg_dollar:$54.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","90.25","86","","","Percent of Total Billed Charges","neg_dollar:$90.25","73.46","70","","","Percent of Total Billed Charges","neg_dollar:$73.46","","52","","104.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","61.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$61.65;102% of Medicaid interim rate","78.71","75","","","Percent of Total Billed Charges","neg_dollar:$78.71","90.25","86","","","Percent of Total Billed Charges","neg_dollar:$90.25","73.46","70","","","Percent of Total Billed Charges","neg_dollar:$73.46","59.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.82;103.5% of Medicaid interim rate","104.95","150","","","Percent of Total Billed Charges","neg_dollar:$162.25;150% of Medicaid interim rate","83.96","80","","","Percent of Total Billed Charges","neg_dollar:$83.96;Percent of Total Billed Charges","96.55","92","","","Percent of Total Billed Charges","neg_dollar:$96.55","54.57","52","","","Percent of Total Billed Charges","neg_dollar:$54.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","104.95","Fee Schedule","","54.00","104.00",""
"INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SC SOPN","A9270","HCPCS","00002-8799-01","NDC","250","RC","","Facility","Outpatient","1","ML","151.15","151.15","","","","151.15","Fee Schedule","","","","","151.15","Fee Schedule","","","","","151.15","Fee Schedule","","","52","","151.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.59","52","","","Percent of Total Billed Charges","neg_dollar:$78.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.59","52","","","Percent of Total Billed Charges","neg_dollar:$78.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","129.98","86","","","Percent of Total Billed Charges","neg_dollar:$129.98","105.80","70","","","Percent of Total Billed Charges","neg_dollar:$105.80","","52","","151.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","88.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$88.80;102% of Medicaid interim rate","113.36","75","","","Percent of Total Billed Charges","neg_dollar:$113.36","129.98","86","","","Percent of Total Billed Charges","neg_dollar:$129.98","105.80","70","","","Percent of Total Billed Charges","neg_dollar:$105.80","86.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$86.15;103.5% of Medicaid interim rate","151.15","150","","","Percent of Total Billed Charges","neg_dollar:$233.68;150% of Medicaid interim rate","120.92","80","","","Percent of Total Billed Charges","neg_dollar:$120.92;Percent of Total Billed Charges","139.05","92","","","Percent of Total Billed Charges","neg_dollar:$139.05","78.59","52","","","Percent of Total Billed Charges","neg_dollar:$78.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","151.15","Fee Schedule","","78.00","151.00",""
"INSULIN GLARGINE 100 UNIT/ML SC SOPN","A9270","HCPCS","00002-7715-01","NDC","637","RC","","Facility","Outpatient","1","ML","104.95","104.95","","","","104.95","Fee Schedule","","","","","104.95","Fee Schedule","101% of Medicare Fee Schedule","","","","104.95","Fee Schedule","","54.57","52","","","Percent of Total Billed Charges","neg_dollar:$54.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","104.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","104.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","90.25","86","","","Percent of Total Billed Charges","neg_dollar:$90.25","73.46","70","","","Percent of Total Billed Charges","neg_dollar:$73.46","54.57","52","","","Percent of Total Billed Charges","neg_dollar:$54.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","61.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$61.65;102% of Medicaid interim rate","78.71","75","","","Percent of Total Billed Charges","neg_dollar:$78.71","90.25","86","","","Percent of Total Billed Charges","neg_dollar:$90.25","73.46","70","","","Percent of Total Billed Charges","neg_dollar:$73.46","59.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.82;103.5% of Medicaid interim rate","104.95","150","","","Percent of Total Billed Charges","neg_dollar:$162.25;150% of Medicaid interim rate","83.96","80","","","Percent of Total Billed Charges","neg_dollar:$83.96;Percent of Total Billed Charges","96.55","92","","","Percent of Total Billed Charges","neg_dollar:$96.55","54.57","52","","","Percent of Total Billed Charges","neg_dollar:$54.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","54.57","52","","","Percent of Total Billed Charges","neg_dollar:$54.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","54.00","104.00",""
"INSULIN GLARGINE 100 UNIT/ML SC SOPN","A9270","HCPCS","00088-2219-05","NDC","637","RC","","Facility","Outpatient","1","ML","90.49","90.49","","","","90.49","Fee Schedule","","","","","90.49","Fee Schedule","101% of Medicare Fee Schedule","","","","90.49","Fee Schedule","","47.05","52","","","Percent of Total Billed Charges","neg_dollar:$47.05;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.49","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.49","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","77.82","86","","","Percent of Total Billed Charges","neg_dollar:$77.82","63.34","70","","","Percent of Total Billed Charges","neg_dollar:$63.34","47.05","52","","","Percent of Total Billed Charges","neg_dollar:$47.05;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.16;102% of Medicaid interim rate","67.87","75","","","Percent of Total Billed Charges","neg_dollar:$67.87","77.82","86","","","Percent of Total Billed Charges","neg_dollar:$77.82","63.34","70","","","Percent of Total Billed Charges","neg_dollar:$63.34","51.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.58;103.5% of Medicaid interim rate","90.49","150","","","Percent of Total Billed Charges","neg_dollar:$139.91;150% of Medicaid interim rate","72.39","80","","","Percent of Total Billed Charges","neg_dollar:$72.39;Percent of Total Billed Charges","83.25","92","","","Percent of Total Billed Charges","neg_dollar:$83.25","47.05","52","","","Percent of Total Billed Charges","neg_dollar:$47.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.05","52","","","Percent of Total Billed Charges","neg_dollar:$47.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.00","90.00",""
"INSULIN GLARGINE 100 UNIT/ML SC SOPN","A9270","HCPCS","00088-2219-05","NDC","250","RC","","Facility","Outpatient","1","ML","90.93","90.93","","","","90.93","Fee Schedule","","","","","90.93","Fee Schedule","","","","","90.93","Fee Schedule","","","52","","90.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.28","52","","","Percent of Total Billed Charges","neg_dollar:$47.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.28","52","","","Percent of Total Billed Charges","neg_dollar:$47.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.20","86","","","Percent of Total Billed Charges","neg_dollar:$78.20","63.65","70","","","Percent of Total Billed Charges","neg_dollar:$63.65","","52","","90.93","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.42;102% of Medicaid interim rate","68.20","75","","","Percent of Total Billed Charges","neg_dollar:$68.20","78.20","86","","","Percent of Total Billed Charges","neg_dollar:$78.20","63.65","70","","","Percent of Total Billed Charges","neg_dollar:$63.65","51.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.83;103.5% of Medicaid interim rate","90.93","150","","","Percent of Total Billed Charges","neg_dollar:$140.59;150% of Medicaid interim rate","72.74","80","","","Percent of Total Billed Charges","neg_dollar:$72.74;Percent of Total Billed Charges","83.66","92","","","Percent of Total Billed Charges","neg_dollar:$83.66","47.28","52","","","Percent of Total Billed Charges","neg_dollar:$47.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","90.93","Fee Schedule","","47.00","90.00",""
"INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SC SOPN","A9270","HCPCS","00002-8799-01","NDC","637","RC","","Facility","Outpatient","1","ML","151.15","151.15","","","","151.15","Fee Schedule","","","","","151.15","Fee Schedule","101% of Medicare Fee Schedule","","","","151.15","Fee Schedule","","78.59","52","","","Percent of Total Billed Charges","neg_dollar:$78.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","151.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","151.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","129.98","86","","","Percent of Total Billed Charges","neg_dollar:$129.98","105.80","70","","","Percent of Total Billed Charges","neg_dollar:$105.80","78.59","52","","","Percent of Total Billed Charges","neg_dollar:$78.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","88.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$88.80;102% of Medicaid interim rate","113.36","75","","","Percent of Total Billed Charges","neg_dollar:$113.36","129.98","86","","","Percent of Total Billed Charges","neg_dollar:$129.98","105.80","70","","","Percent of Total Billed Charges","neg_dollar:$105.80","86.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$86.15;103.5% of Medicaid interim rate","151.15","150","","","Percent of Total Billed Charges","neg_dollar:$233.68;150% of Medicaid interim rate","120.92","80","","","Percent of Total Billed Charges","neg_dollar:$120.92;Percent of Total Billed Charges","139.05","92","","","Percent of Total Billed Charges","neg_dollar:$139.05","78.59","52","","","Percent of Total Billed Charges","neg_dollar:$78.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","78.59","52","","","Percent of Total Billed Charges","neg_dollar:$78.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","78.00","151.00",""
"INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SC SOPN","A9270","HCPCS","00002-8799-59","NDC","250","RC","","Facility","Outpatient","1","ML","88.80","88.80","","","","88.80","Fee Schedule","","","","","88.80","Fee Schedule","","","","","88.80","Fee Schedule","","","52","","88.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.17","52","","","Percent of Total Billed Charges","neg_dollar:$46.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.17","52","","","Percent of Total Billed Charges","neg_dollar:$46.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.36","86","","","Percent of Total Billed Charges","neg_dollar:$76.36","62.16","70","","","Percent of Total Billed Charges","neg_dollar:$62.16","","52","","88.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.16;102% of Medicaid interim rate","66.60","75","","","Percent of Total Billed Charges","neg_dollar:$66.60","76.36","86","","","Percent of Total Billed Charges","neg_dollar:$76.36","62.16","70","","","Percent of Total Billed Charges","neg_dollar:$62.16","50.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.61;103.5% of Medicaid interim rate","88.80","150","","","Percent of Total Billed Charges","neg_dollar:$137.28;150% of Medicaid interim rate","71.04","80","","","Percent of Total Billed Charges","neg_dollar:$71.04;Percent of Total Billed Charges","81.69","92","","","Percent of Total Billed Charges","neg_dollar:$81.69","46.17","52","","","Percent of Total Billed Charges","neg_dollar:$46.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","88.80","Fee Schedule","","46.00","88.00",""
"INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUPN","A9270","HCPCS","00002-8805-01","NDC","637","RC","","Facility","Outpatient","1","ML","129.95","129.95","","","","129.95","Fee Schedule","","","","","129.95","Fee Schedule","101% of Medicare Fee Schedule","","","","129.95","Fee Schedule","","67.57","52","","","Percent of Total Billed Charges","neg_dollar:$67.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","129.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","129.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","111.75","86","","","Percent of Total Billed Charges","neg_dollar:$111.75","90.96","70","","","Percent of Total Billed Charges","neg_dollar:$90.96","67.57","52","","","Percent of Total Billed Charges","neg_dollar:$67.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","76.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$76.34;102% of Medicaid interim rate","97.46","75","","","Percent of Total Billed Charges","neg_dollar:$97.46","111.75","86","","","Percent of Total Billed Charges","neg_dollar:$111.75","90.96","70","","","Percent of Total Billed Charges","neg_dollar:$90.96","74.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$74.07;103.5% of Medicaid interim rate","129.95","150","","","Percent of Total Billed Charges","neg_dollar:$200.90;150% of Medicaid interim rate","103.96","80","","","Percent of Total Billed Charges","neg_dollar:$103.96;Percent of Total Billed Charges","119.55","92","","","Percent of Total Billed Charges","neg_dollar:$119.55","67.57","52","","","Percent of Total Billed Charges","neg_dollar:$67.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","67.57","52","","","Percent of Total Billed Charges","neg_dollar:$67.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","67.00","129.00",""
"INSULIN GLARGINE 100 UNIT/ML SC SOPN","A9270","HCPCS","00088-2219-00","NDC","637","RC","","Facility","Outpatient","1","ML","88.80","88.80","","","","88.80","Fee Schedule","","","","","88.80","Fee Schedule","101% of Medicare Fee Schedule","","","","88.80","Fee Schedule","","46.17","52","","","Percent of Total Billed Charges","neg_dollar:$46.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.36","86","","","Percent of Total Billed Charges","neg_dollar:$76.36","62.16","70","","","Percent of Total Billed Charges","neg_dollar:$62.16","46.17","52","","","Percent of Total Billed Charges","neg_dollar:$46.17;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.16;102% of Medicaid interim rate","66.60","75","","","Percent of Total Billed Charges","neg_dollar:$66.60","76.36","86","","","Percent of Total Billed Charges","neg_dollar:$76.36","62.16","70","","","Percent of Total Billed Charges","neg_dollar:$62.16","50.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.61;103.5% of Medicaid interim rate","88.80","150","","","Percent of Total Billed Charges","neg_dollar:$137.28;150% of Medicaid interim rate","71.04","80","","","Percent of Total Billed Charges","neg_dollar:$71.04;Percent of Total Billed Charges","81.69","92","","","Percent of Total Billed Charges","neg_dollar:$81.69","46.17","52","","","Percent of Total Billed Charges","neg_dollar:$46.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.17","52","","","Percent of Total Billed Charges","neg_dollar:$46.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.00","88.00",""
"TAKE HOME DOXYCYCLINE HYCLATE 100 MG PO TABS (QTY:14)","A9270","HCPCS","09999-5000-05","NDC","253","RC","","Facility","Outpatient","1","EA","4.73","4.73","4.73","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2.46","52","","","Percent of Total Billed Charges","neg_dollar:$2.46;101% Medicare Outpatient Cost to Charge Ratio of 52%","4.73","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2.46","52","","","Percent of Total Billed Charges","neg_dollar:$2.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.46","52","","","Percent of Total Billed Charges","neg_dollar:$2.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.46","52","","","Percent of Total Billed Charges","neg_dollar:$2.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.07","86","","","Percent of Total Billed Charges","neg_dollar:$4.07","3.31","70","","","Percent of Total Billed Charges","neg_dollar:$3.31","2.46","52","","","Percent of Total Billed Charges","neg_dollar:$2.46;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.78;102% of Medicaid interim rate","3.55","75","","","Percent of Total Billed Charges","neg_dollar:$3.55","4.07","86","","","Percent of Total Billed Charges","neg_dollar:$4.07","3.31","70","","","Percent of Total Billed Charges","neg_dollar:$3.31","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;103.5% of Medicaid interim rate","4.73","150","","","Percent of Total Billed Charges","neg_dollar:$7.32;150% of Medicaid interim rate","3.79","80","","","Percent of Total Billed Charges","neg_dollar:$3.79;Percent of Total Billed Charges","4.36","92","","","Percent of Total Billed Charges","neg_dollar:$4.36","2.46","52","","","Percent of Total Billed Charges","neg_dollar:$2.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.46","52","","","Percent of Total Billed Charges","neg_dollar:$2.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"VITAMIN B-12 1000 MCG PO TABS","A9270","HCPCS","77333-938-10","NDC","250","RC","","Facility","Outpatient","1","EA","2.55","2.55","","","","2.55","Fee Schedule","","","","","2.55","Fee Schedule","","","","","2.55","Fee Schedule","","","52","","2.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","52","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","52","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.19","86","","","Percent of Total Billed Charges","neg_dollar:$2.19","1.78","70","","","Percent of Total Billed Charges","neg_dollar:$1.78","","52","","2.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.49;102% of Medicaid interim rate","1.91","75","","","Percent of Total Billed Charges","neg_dollar:$1.91","2.19","86","","","Percent of Total Billed Charges","neg_dollar:$2.19","1.78","70","","","Percent of Total Billed Charges","neg_dollar:$1.78","1.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.45;103.5% of Medicaid interim rate","2.55","150","","","Percent of Total Billed Charges","neg_dollar:$3.94;150% of Medicaid interim rate","2.04","80","","","Percent of Total Billed Charges","neg_dollar:$2.04;Percent of Total Billed Charges","2.34","92","","","Percent of Total Billed Charges","neg_dollar:$2.34","1.32","52","","","Percent of Total Billed Charges","neg_dollar:$1.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.55","Fee Schedule","","1.00","2.00",""
"FISH OIL 1000 MG PO CAPS","A9270","HCPCS","77333-308-25","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"VITAMIN B-12 1000 MCG PO TABS","A9270","HCPCS","77333-938-25","NDC","637","RC","","Facility","Outpatient","1","EA","1.16","1.16","","","","1.16","Fee Schedule","","","","","1.16","Fee Schedule","101% of Medicare Fee Schedule","","","","1.16","Fee Schedule","","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","86","","","Percent of Total Billed Charges","neg_dollar:$1","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% of Medicaid interim rate","0.87","75","","","Percent of Total Billed Charges","neg_dollar:$0.87","1.00","86","","","Percent of Total Billed Charges","neg_dollar:$1","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.66;103.5% of Medicaid interim rate","1.16","150","","","Percent of Total Billed Charges","neg_dollar:$1.80;150% of Medicaid interim rate","0.93","80","","","Percent of Total Billed Charges","neg_dollar:$0.93;Percent of Total Billed Charges","1.07","92","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"VITAMIN B-12 1000 MCG PO TABS","A9270","HCPCS","77333-938-25","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"FISH OIL 1000 MG PO CAPS","A9270","HCPCS","77333-308-25","NDC","637","RC","","Facility","Outpatient","1","EA","1.26","1.26","","","","1.26","Fee Schedule","","","","","1.26","Fee Schedule","101% of Medicare Fee Schedule","","","","1.26","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","86","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","70","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;102% of Medicaid interim rate","0.94","75","","","Percent of Total Billed Charges","neg_dollar:$0.94","1.08","86","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","70","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.72;103.5% of Medicaid interim rate","1.26","150","","","Percent of Total Billed Charges","neg_dollar:$1.95;150% of Medicaid interim rate","1.01","80","","","Percent of Total Billed Charges","neg_dollar:$1.01;Percent of Total Billed Charges","1.16","92","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"NYSTATIN 100000 UNIT/ML MT SUSP","A9270","HCPCS","00121-0868-00","NDC","250","RC","","Facility","Outpatient","1","EA","12.10","12.10","","","","12.10","Fee Schedule","","","","","12.10","Fee Schedule","","","","","12.10","Fee Schedule","","","52","","12.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.29","52","","","Percent of Total Billed Charges","neg_dollar:$6.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.29","52","","","Percent of Total Billed Charges","neg_dollar:$6.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.40","86","","","Percent of Total Billed Charges","neg_dollar:$10.40","8.46","70","","","Percent of Total Billed Charges","neg_dollar:$8.46","","52","","12.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.10;102% of Medicaid interim rate","9.07","75","","","Percent of Total Billed Charges","neg_dollar:$9.07","10.40","86","","","Percent of Total Billed Charges","neg_dollar:$10.40","8.46","70","","","Percent of Total Billed Charges","neg_dollar:$8.46","6.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.89;103.5% of Medicaid interim rate","12.10","150","","","Percent of Total Billed Charges","neg_dollar:$18.70;150% of Medicaid interim rate","9.68","80","","","Percent of Total Billed Charges","neg_dollar:$9.68;Percent of Total Billed Charges","11.13","92","","","Percent of Total Billed Charges","neg_dollar:$11.13","6.29","52","","","Percent of Total Billed Charges","neg_dollar:$6.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.10","Fee Schedule","","6.00","12.00",""
"NYSTATIN 100000 UNIT/ML MT SUSP","A9270","HCPCS","00121-4785-05","NDC","250","RC","","Facility","Outpatient","1","EA","6.05","6.05","","","","6.05","Fee Schedule","","","","","6.05","Fee Schedule","","","","","6.05","Fee Schedule","","","52","","6.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.14","52","","","Percent of Total Billed Charges","neg_dollar:$3.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.14","52","","","Percent of Total Billed Charges","neg_dollar:$3.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.20","86","","","Percent of Total Billed Charges","neg_dollar:$5.20","4.23","70","","","Percent of Total Billed Charges","neg_dollar:$4.23","","52","","6.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.55;102% of Medicaid interim rate","4.53","75","","","Percent of Total Billed Charges","neg_dollar:$4.53","5.20","86","","","Percent of Total Billed Charges","neg_dollar:$5.20","4.23","70","","","Percent of Total Billed Charges","neg_dollar:$4.23","3.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.44;103.5% of Medicaid interim rate","6.05","150","","","Percent of Total Billed Charges","neg_dollar:$9.35;150% of Medicaid interim rate","4.84","80","","","Percent of Total Billed Charges","neg_dollar:$4.84;Percent of Total Billed Charges","5.56","92","","","Percent of Total Billed Charges","neg_dollar:$5.56","3.14","52","","","Percent of Total Billed Charges","neg_dollar:$3.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","6.05","Fee Schedule","","3.00","6.00",""
"NYSTATIN 100000 UNIT/GM EX POWD","A9270","HCPCS","00574-2008-15","NDC","250","RC","","Facility","Outpatient","1","EA","31.85","31.85","","","","31.85","Fee Schedule","","","","","31.85","Fee Schedule","","","","","31.85","Fee Schedule","","","52","","31.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.56","52","","","Percent of Total Billed Charges","neg_dollar:$16.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.56","52","","","Percent of Total Billed Charges","neg_dollar:$16.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.39","86","","","Percent of Total Billed Charges","neg_dollar:$27.39","22.29","70","","","Percent of Total Billed Charges","neg_dollar:$22.29","","52","","31.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","18.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.71;102% of Medicaid interim rate","23.88","75","","","Percent of Total Billed Charges","neg_dollar:$23.88","27.39","86","","","Percent of Total Billed Charges","neg_dollar:$27.39","22.29","70","","","Percent of Total Billed Charges","neg_dollar:$22.29","18.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.15;103.5% of Medicaid interim rate","31.85","150","","","Percent of Total Billed Charges","neg_dollar:$49.24;150% of Medicaid interim rate","25.48","80","","","Percent of Total Billed Charges","neg_dollar:$25.48;Percent of Total Billed Charges","29.30","92","","","Percent of Total Billed Charges","neg_dollar:$29.30","16.56","52","","","Percent of Total Billed Charges","neg_dollar:$16.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","31.85","Fee Schedule","","16.00","31.00",""
"NYSTATIN 100000 UNIT/ML MT SUSP","A9270","HCPCS","00121-0868-05","NDC","250","RC","","Facility","Outpatient","1","EA","12.70","12.70","","","","12.70","Fee Schedule","","","","","12.70","Fee Schedule","","","","","12.70","Fee Schedule","","","52","","12.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.60","52","","","Percent of Total Billed Charges","neg_dollar:$6.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.60","52","","","Percent of Total Billed Charges","neg_dollar:$6.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.92","86","","","Percent of Total Billed Charges","neg_dollar:$10.92","8.88","70","","","Percent of Total Billed Charges","neg_dollar:$8.88","","52","","12.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.46;102% of Medicaid interim rate","9.52","75","","","Percent of Total Billed Charges","neg_dollar:$9.52","10.92","86","","","Percent of Total Billed Charges","neg_dollar:$10.92","8.88","70","","","Percent of Total Billed Charges","neg_dollar:$8.88","7.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.23;103.5% of Medicaid interim rate","12.70","150","","","Percent of Total Billed Charges","neg_dollar:$19.63;150% of Medicaid interim rate","10.16","80","","","Percent of Total Billed Charges","neg_dollar:$10.16;Percent of Total Billed Charges","11.68","92","","","Percent of Total Billed Charges","neg_dollar:$11.68","6.60","52","","","Percent of Total Billed Charges","neg_dollar:$6.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.70","Fee Schedule","","6.00","12.00",""
"NYSTATIN 100000 UNIT/GM EX POWD","A9270","HCPCS","00574-2008-30","NDC","250","RC","","Facility","Outpatient","1","EA","53.25","53.25","","","","53.25","Fee Schedule","","","","","53.25","Fee Schedule","","","","","53.25","Fee Schedule","","","52","","53.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.79","86","","","Percent of Total Billed Charges","neg_dollar:$45.79","37.27","70","","","Percent of Total Billed Charges","neg_dollar:$37.27","","52","","53.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","31.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.28;102% of Medicaid interim rate","39.93","75","","","Percent of Total Billed Charges","neg_dollar:$39.93","45.79","86","","","Percent of Total Billed Charges","neg_dollar:$45.79","37.27","70","","","Percent of Total Billed Charges","neg_dollar:$37.27","30.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.35;103.5% of Medicaid interim rate","53.25","150","","","Percent of Total Billed Charges","neg_dollar:$82.32;150% of Medicaid interim rate","42.60","80","","","Percent of Total Billed Charges","neg_dollar:$42.60;Percent of Total Billed Charges","48.99","92","","","Percent of Total Billed Charges","neg_dollar:$48.99","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","53.25","Fee Schedule","","27.00","53.00",""
"NYSTATIN 100000 UNIT/GM EX POWD","A9270","HCPCS","42806-186-30","NDC","250","RC","","Facility","Outpatient","1","EA","25.95","25.95","","","","25.95","Fee Schedule","","","","","25.95","Fee Schedule","","","","","25.95","Fee Schedule","","","52","","25.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","22.31","86","","","Percent of Total Billed Charges","neg_dollar:$22.31","18.16","70","","","Percent of Total Billed Charges","neg_dollar:$18.16","","52","","25.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","15.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.24;102% of Medicaid interim rate","19.46","75","","","Percent of Total Billed Charges","neg_dollar:$19.46","22.31","86","","","Percent of Total Billed Charges","neg_dollar:$22.31","18.16","70","","","Percent of Total Billed Charges","neg_dollar:$18.16","14.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.79;103.5% of Medicaid interim rate","25.95","150","","","Percent of Total Billed Charges","neg_dollar:$40.11;150% of Medicaid interim rate","20.76","80","","","Percent of Total Billed Charges","neg_dollar:$20.76;Percent of Total Billed Charges","23.87","92","","","Percent of Total Billed Charges","neg_dollar:$23.87","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.95","Fee Schedule","","13.00","25.00",""
"NYSTATIN 100000 UNIT/GM EX CREA","A9270","HCPCS","00713-0678-31","NDC","250","RC","","Facility","Outpatient","1","EA","32.50","32.50","","","","32.50","Fee Schedule","","","","","32.50","Fee Schedule","","","","","32.50","Fee Schedule","","","52","","32.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.95","86","","","Percent of Total Billed Charges","neg_dollar:$27.95","22.75","70","","","Percent of Total Billed Charges","neg_dollar:$22.75","","52","","32.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","19.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.09;102% of Medicaid interim rate","24.37","75","","","Percent of Total Billed Charges","neg_dollar:$24.37","27.95","86","","","Percent of Total Billed Charges","neg_dollar:$27.95","22.75","70","","","Percent of Total Billed Charges","neg_dollar:$22.75","18.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.52;103.5% of Medicaid interim rate","32.50","150","","","Percent of Total Billed Charges","neg_dollar:$50.24;150% of Medicaid interim rate","26.00","80","","","Percent of Total Billed Charges","neg_dollar:$26;Percent of Total Billed Charges","29.90","92","","","Percent of Total Billed Charges","neg_dollar:$29.90","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","32.50","Fee Schedule","","16.00","32.00",""
"NYSTATIN 100000 UNIT/GM EX CREA","A9270","HCPCS","00713-0678-31","NDC","637","RC","","Facility","Outpatient","1","EA","32.50","32.50","","","","32.50","Fee Schedule","","","","","32.50","Fee Schedule","101% of Medicare Fee Schedule","","","","32.50","Fee Schedule","","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","32.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","32.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","27.95","86","","","Percent of Total Billed Charges","neg_dollar:$27.95","22.75","70","","","Percent of Total Billed Charges","neg_dollar:$22.75","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.09;102% of Medicaid interim rate","24.37","75","","","Percent of Total Billed Charges","neg_dollar:$24.37","27.95","86","","","Percent of Total Billed Charges","neg_dollar:$27.95","22.75","70","","","Percent of Total Billed Charges","neg_dollar:$22.75","18.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.52;103.5% of Medicaid interim rate","32.50","150","","","Percent of Total Billed Charges","neg_dollar:$50.24;150% of Medicaid interim rate","26.00","80","","","Percent of Total Billed Charges","neg_dollar:$26;Percent of Total Billed Charges","29.90","92","","","Percent of Total Billed Charges","neg_dollar:$29.90","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","32.00",""
"NYSTATIN 100000 UNIT/GM EX POWD","A9270","HCPCS","00574-2008-15","NDC","637","RC","","Facility","Outpatient","1","EA","31.85","31.85","","","","31.85","Fee Schedule","","","","","31.85","Fee Schedule","101% of Medicare Fee Schedule","","","","31.85","Fee Schedule","","16.56","52","","","Percent of Total Billed Charges","neg_dollar:$16.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","27.39","86","","","Percent of Total Billed Charges","neg_dollar:$27.39","22.29","70","","","Percent of Total Billed Charges","neg_dollar:$22.29","16.56","52","","","Percent of Total Billed Charges","neg_dollar:$16.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","18.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.71;102% of Medicaid interim rate","23.88","75","","","Percent of Total Billed Charges","neg_dollar:$23.88","27.39","86","","","Percent of Total Billed Charges","neg_dollar:$27.39","22.29","70","","","Percent of Total Billed Charges","neg_dollar:$22.29","18.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.15;103.5% of Medicaid interim rate","31.85","150","","","Percent of Total Billed Charges","neg_dollar:$49.24;150% of Medicaid interim rate","25.48","80","","","Percent of Total Billed Charges","neg_dollar:$25.48;Percent of Total Billed Charges","29.30","92","","","Percent of Total Billed Charges","neg_dollar:$29.30","16.56","52","","","Percent of Total Billed Charges","neg_dollar:$16.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.56","52","","","Percent of Total Billed Charges","neg_dollar:$16.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","31.00",""
"NYSTATIN 100000 UNIT/GM EX POWD","A9270","HCPCS","75907-060-30","NDC","250","RC","","Facility","Outpatient","1","EA","25.95","25.95","","","","25.95","Fee Schedule","","","","","25.95","Fee Schedule","","","","","25.95","Fee Schedule","","","52","","25.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","22.31","86","","","Percent of Total Billed Charges","neg_dollar:$22.31","18.16","70","","","Percent of Total Billed Charges","neg_dollar:$18.16","","52","","25.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","15.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.24;102% of Medicaid interim rate","19.46","75","","","Percent of Total Billed Charges","neg_dollar:$19.46","22.31","86","","","Percent of Total Billed Charges","neg_dollar:$22.31","18.16","70","","","Percent of Total Billed Charges","neg_dollar:$18.16","14.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.79;103.5% of Medicaid interim rate","25.95","150","","","Percent of Total Billed Charges","neg_dollar:$40.11;150% of Medicaid interim rate","20.76","80","","","Percent of Total Billed Charges","neg_dollar:$20.76;Percent of Total Billed Charges","23.87","92","","","Percent of Total Billed Charges","neg_dollar:$23.87","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.95","Fee Schedule","","13.00","25.00",""
"NYSTATIN 100000 UNIT/GM EX POWD","A9270","HCPCS","00574-2008-30","NDC","637","RC","","Facility","Outpatient","1","EA","53.25","53.25","","","","53.25","Fee Schedule","","","","","53.25","Fee Schedule","101% of Medicare Fee Schedule","","","","53.25","Fee Schedule","","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","53.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","53.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.79","86","","","Percent of Total Billed Charges","neg_dollar:$45.79","37.27","70","","","Percent of Total Billed Charges","neg_dollar:$37.27","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;105% Medicare Outpatient Cost to Charge Ratio of 52%","31.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.28;102% of Medicaid interim rate","39.93","75","","","Percent of Total Billed Charges","neg_dollar:$39.93","45.79","86","","","Percent of Total Billed Charges","neg_dollar:$45.79","37.27","70","","","Percent of Total Billed Charges","neg_dollar:$37.27","30.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.35;103.5% of Medicaid interim rate","53.25","150","","","Percent of Total Billed Charges","neg_dollar:$82.32;150% of Medicaid interim rate","42.60","80","","","Percent of Total Billed Charges","neg_dollar:$42.60;Percent of Total Billed Charges","48.99","92","","","Percent of Total Billed Charges","neg_dollar:$48.99","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.00","53.00",""
"NYSTATIN 100000 UNIT/GM EX POWD","A9270","HCPCS","42806-186-30","NDC","637","RC","","Facility","Outpatient","1","EA","25.95","25.95","","","","25.95","Fee Schedule","","","","","25.95","Fee Schedule","101% of Medicare Fee Schedule","","","","25.95","Fee Schedule","","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.31","86","","","Percent of Total Billed Charges","neg_dollar:$22.31","18.16","70","","","Percent of Total Billed Charges","neg_dollar:$18.16","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","15.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.24;102% of Medicaid interim rate","19.46","75","","","Percent of Total Billed Charges","neg_dollar:$19.46","22.31","86","","","Percent of Total Billed Charges","neg_dollar:$22.31","18.16","70","","","Percent of Total Billed Charges","neg_dollar:$18.16","14.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.79;103.5% of Medicaid interim rate","25.95","150","","","Percent of Total Billed Charges","neg_dollar:$40.11;150% of Medicaid interim rate","20.76","80","","","Percent of Total Billed Charges","neg_dollar:$20.76;Percent of Total Billed Charges","23.87","92","","","Percent of Total Billed Charges","neg_dollar:$23.87","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","25.00",""
"NYSTATIN 100000 UNIT/GM EX CREA","A9270","HCPCS","45802-059-11","NDC","637","RC","","Facility","Outpatient","1","EA","33.60","33.60","","","","33.60","Fee Schedule","","","","","33.60","Fee Schedule","101% of Medicare Fee Schedule","","","","33.60","Fee Schedule","","17.47","52","","","Percent of Total Billed Charges","neg_dollar:$17.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","33.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","33.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.89","86","","","Percent of Total Billed Charges","neg_dollar:$28.89","23.52","70","","","Percent of Total Billed Charges","neg_dollar:$23.52","17.47","52","","","Percent of Total Billed Charges","neg_dollar:$17.47;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.73;102% of Medicaid interim rate","25.20","75","","","Percent of Total Billed Charges","neg_dollar:$25.20","28.89","86","","","Percent of Total Billed Charges","neg_dollar:$28.89","23.52","70","","","Percent of Total Billed Charges","neg_dollar:$23.52","19.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.15;103.5% of Medicaid interim rate","33.60","150","","","Percent of Total Billed Charges","neg_dollar:$51.94;150% of Medicaid interim rate","26.88","80","","","Percent of Total Billed Charges","neg_dollar:$26.88;Percent of Total Billed Charges","30.91","92","","","Percent of Total Billed Charges","neg_dollar:$30.91","17.47","52","","","Percent of Total Billed Charges","neg_dollar:$17.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.47","52","","","Percent of Total Billed Charges","neg_dollar:$17.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","33.00",""
"NYSTATIN 100000 UNIT/GM EX POWD","A9270","HCPCS","75907-060-30","NDC","637","RC","","Facility","Outpatient","1","EA","25.95","25.95","","","","25.95","Fee Schedule","","","","","25.95","Fee Schedule","101% of Medicare Fee Schedule","","","","25.95","Fee Schedule","","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.31","86","","","Percent of Total Billed Charges","neg_dollar:$22.31","18.16","70","","","Percent of Total Billed Charges","neg_dollar:$18.16","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","15.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.24;102% of Medicaid interim rate","19.46","75","","","Percent of Total Billed Charges","neg_dollar:$19.46","22.31","86","","","Percent of Total Billed Charges","neg_dollar:$22.31","18.16","70","","","Percent of Total Billed Charges","neg_dollar:$18.16","14.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.79;103.5% of Medicaid interim rate","25.95","150","","","Percent of Total Billed Charges","neg_dollar:$40.11;150% of Medicaid interim rate","20.76","80","","","Percent of Total Billed Charges","neg_dollar:$20.76;Percent of Total Billed Charges","23.87","92","","","Percent of Total Billed Charges","neg_dollar:$23.87","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.49","52","","","Percent of Total Billed Charges","neg_dollar:$13.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","25.00",""
"NYSTATIN 100000 UNIT/GM EX POWD","A9270","HCPCS","69315-306-30","NDC","637","RC","","Facility","Outpatient","1","EA","53.25","53.25","","","","53.25","Fee Schedule","","","","","53.25","Fee Schedule","101% of Medicare Fee Schedule","","","","53.25","Fee Schedule","","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","53.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","53.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.79","86","","","Percent of Total Billed Charges","neg_dollar:$45.79","37.27","70","","","Percent of Total Billed Charges","neg_dollar:$37.27","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;105% Medicare Outpatient Cost to Charge Ratio of 52%","31.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.28;102% of Medicaid interim rate","39.93","75","","","Percent of Total Billed Charges","neg_dollar:$39.93","45.79","86","","","Percent of Total Billed Charges","neg_dollar:$45.79","37.27","70","","","Percent of Total Billed Charges","neg_dollar:$37.27","30.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.35;103.5% of Medicaid interim rate","53.25","150","","","Percent of Total Billed Charges","neg_dollar:$82.32;150% of Medicaid interim rate","42.60","80","","","Percent of Total Billed Charges","neg_dollar:$42.60;Percent of Total Billed Charges","48.99","92","","","Percent of Total Billed Charges","neg_dollar:$48.99","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.69","52","","","Percent of Total Billed Charges","neg_dollar:$27.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.00","53.00",""
"FLUTICASONE-SALMETEROL 100-50 MCG/ACT IN AEPB","A9270","HCPCS","00173-0695-04","NDC","250","RC","","Facility","Outpatient","1","EA","4.98","4.98","","","","4.98","Fee Schedule","","","","","4.98","Fee Schedule","","","","","4.98","Fee Schedule","","","52","","4.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.58","52","","","Percent of Total Billed Charges","neg_dollar:$2.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.58","52","","","Percent of Total Billed Charges","neg_dollar:$2.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.28","86","","","Percent of Total Billed Charges","neg_dollar:$4.28","3.48","70","","","Percent of Total Billed Charges","neg_dollar:$3.48","","52","","4.98","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.92;102% of Medicaid interim rate","3.73","75","","","Percent of Total Billed Charges","neg_dollar:$3.73","4.28","86","","","Percent of Total Billed Charges","neg_dollar:$4.28","3.48","70","","","Percent of Total Billed Charges","neg_dollar:$3.48","2.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.83;103.5% of Medicaid interim rate","4.98","150","","","Percent of Total Billed Charges","neg_dollar:$7.69;150% of Medicaid interim rate","3.98","80","","","Percent of Total Billed Charges","neg_dollar:$3.98;Percent of Total Billed Charges","4.58","92","","","Percent of Total Billed Charges","neg_dollar:$4.58","2.58","52","","","Percent of Total Billed Charges","neg_dollar:$2.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.98","Fee Schedule","","2.00","4.00",""
"FLUTICASONE-SALMETEROL 100-50 MCG/ACT IN AEPB","A9270","HCPCS","00054-0326-56","NDC","250","RC","","Facility","Outpatient","1","EA","1.89","1.89","","","","1.89","Fee Schedule","","","","","1.89","Fee Schedule","","","","","1.89","Fee Schedule","","","52","","1.89","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.62","86","","","Percent of Total Billed Charges","neg_dollar:$1.62","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","","52","","1.89","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% of Medicaid interim rate","1.41","75","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.62","86","","","Percent of Total Billed Charges","neg_dollar:$1.62","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.07;103.5% of Medicaid interim rate","1.89","150","","","Percent of Total Billed Charges","neg_dollar:$2.92;150% of Medicaid interim rate","1.51","80","","","Percent of Total Billed Charges","neg_dollar:$1.51;Percent of Total Billed Charges","1.74","92","","","Percent of Total Billed Charges","neg_dollar:$1.74","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.89","Fee Schedule","","1.00","1.00",""
"FLUTICASONE-SALMETEROL 100-50 MCG/ACT IN AEPB","A9270","HCPCS","00054-0326-56","NDC","637","RC","","Facility","Outpatient","1","UN","1.89","1.89","","","","1.89","Fee Schedule","","","","","1.89","Fee Schedule","101% of Medicare Fee Schedule","","","","1.89","Fee Schedule","","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.89","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.89","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.62","86","","","Percent of Total Billed Charges","neg_dollar:$1.62","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% of Medicaid interim rate","1.41","75","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.62","86","","","Percent of Total Billed Charges","neg_dollar:$1.62","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.07;103.5% of Medicaid interim rate","1.89","150","","","Percent of Total Billed Charges","neg_dollar:$2.92;150% of Medicaid interim rate","1.51","80","","","Percent of Total Billed Charges","neg_dollar:$1.51;Percent of Total Billed Charges","1.74","92","","","Percent of Total Billed Charges","neg_dollar:$1.74","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML PO SYRP","A9270","HCPCS","00536-1313-85","NDC","250","RC","","Facility","Outpatient","5","ML","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"CARBIDOPA-LEVODOPA 10-100 MG PO TABS","A9270","HCPCS","00093-9701-01","NDC","637","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","A9270","HCPCS","00173-0682-24","NDC","250","RC","","Facility","Outpatient","1","UN","35.50","35.50","","","","35.50","Fee Schedule","","","","","35.50","Fee Schedule","","","","","35.50","Fee Schedule","","","52","","35.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","18.46","52","","","Percent of Total Billed Charges","neg_dollar:$18.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.46","52","","","Percent of Total Billed Charges","neg_dollar:$18.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.53","86","","","Percent of Total Billed Charges","neg_dollar:$30.53","24.84","70","","","Percent of Total Billed Charges","neg_dollar:$24.84","","52","","35.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","20.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.85;102% of Medicaid interim rate","26.62","75","","","Percent of Total Billed Charges","neg_dollar:$26.62","30.53","86","","","Percent of Total Billed Charges","neg_dollar:$30.53","24.84","70","","","Percent of Total Billed Charges","neg_dollar:$24.84","20.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.23;103.5% of Medicaid interim rate","35.50","150","","","Percent of Total Billed Charges","neg_dollar:$54.88;150% of Medicaid interim rate","28.40","80","","","Percent of Total Billed Charges","neg_dollar:$28.40;Percent of Total Billed Charges","32.66","92","","","Percent of Total Billed Charges","neg_dollar:$32.66","18.46","52","","","Percent of Total Billed Charges","neg_dollar:$18.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","35.50","Fee Schedule","","18.00","35.00",""
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","A9270","HCPCS","00173-0682-24","NDC","637","RC","","Facility","Outpatient","1","UN","35.50","35.50","","","","35.50","Fee Schedule","","","","","35.50","Fee Schedule","101% of Medicare Fee Schedule","","","","35.50","Fee Schedule","","18.46","52","","","Percent of Total Billed Charges","neg_dollar:$18.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","35.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","35.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","30.53","86","","","Percent of Total Billed Charges","neg_dollar:$30.53","24.84","70","","","Percent of Total Billed Charges","neg_dollar:$24.84","18.46","52","","","Percent of Total Billed Charges","neg_dollar:$18.46;105% Medicare Outpatient Cost to Charge Ratio of 52%","20.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.85;102% of Medicaid interim rate","26.62","75","","","Percent of Total Billed Charges","neg_dollar:$26.62","30.53","86","","","Percent of Total Billed Charges","neg_dollar:$30.53","24.84","70","","","Percent of Total Billed Charges","neg_dollar:$24.84","20.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.23;103.5% of Medicaid interim rate","35.50","150","","","Percent of Total Billed Charges","neg_dollar:$54.88;150% of Medicaid interim rate","28.40","80","","","Percent of Total Billed Charges","neg_dollar:$28.40;Percent of Total Billed Charges","32.66","92","","","Percent of Total Billed Charges","neg_dollar:$32.66","18.46","52","","","Percent of Total Billed Charges","neg_dollar:$18.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","18.46","52","","","Percent of Total Billed Charges","neg_dollar:$18.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","18.00","35.00",""
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","A9270","HCPCS","00093-3174-31","NDC","637","RC","","Facility","Outpatient","1","UN","50.10","50.10","","","","50.10","Fee Schedule","","","","","50.10","Fee Schedule","101% of Medicare Fee Schedule","","","","50.10","Fee Schedule","","26.05","52","","","Percent of Total Billed Charges","neg_dollar:$26.05;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","50.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","50.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","43.08","86","","","Percent of Total Billed Charges","neg_dollar:$43.08","35.07","70","","","Percent of Total Billed Charges","neg_dollar:$35.07","26.05","52","","","Percent of Total Billed Charges","neg_dollar:$26.05;105% Medicare Outpatient Cost to Charge Ratio of 52%","29.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.43;102% of Medicaid interim rate","37.57","75","","","Percent of Total Billed Charges","neg_dollar:$37.57","43.08","86","","","Percent of Total Billed Charges","neg_dollar:$43.08","35.07","70","","","Percent of Total Billed Charges","neg_dollar:$35.07","28.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.55;103.5% of Medicaid interim rate","50.10","150","","","Percent of Total Billed Charges","neg_dollar:$77.45;150% of Medicaid interim rate","40.08","80","","","Percent of Total Billed Charges","neg_dollar:$40.08;Percent of Total Billed Charges","46.09","92","","","Percent of Total Billed Charges","neg_dollar:$46.09","26.05","52","","","Percent of Total Billed Charges","neg_dollar:$26.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","26.05","52","","","Percent of Total Billed Charges","neg_dollar:$26.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","50.00",""
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","A9270","HCPCS","69097-142-60","NDC","637","RC","","Facility","Outpatient","1","UN","39.10","39.10","","","","39.10","Fee Schedule","","","","","39.10","Fee Schedule","101% of Medicare Fee Schedule","","","","39.10","Fee Schedule","","20.33","52","","","Percent of Total Billed Charges","neg_dollar:$20.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","39.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","39.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","33.62","86","","","Percent of Total Billed Charges","neg_dollar:$33.62","27.37","70","","","Percent of Total Billed Charges","neg_dollar:$27.37","20.33","52","","","Percent of Total Billed Charges","neg_dollar:$20.33;105% Medicare Outpatient Cost to Charge Ratio of 52%","22.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.97;102% of Medicaid interim rate","29.32","75","","","Percent of Total Billed Charges","neg_dollar:$29.32","33.62","86","","","Percent of Total Billed Charges","neg_dollar:$33.62","27.37","70","","","Percent of Total Billed Charges","neg_dollar:$27.37","22.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.28;103.5% of Medicaid interim rate","39.10","150","","","Percent of Total Billed Charges","neg_dollar:$60.45;150% of Medicaid interim rate","31.28","80","","","Percent of Total Billed Charges","neg_dollar:$31.28;Percent of Total Billed Charges","35.97","92","","","Percent of Total Billed Charges","neg_dollar:$35.97","20.33","52","","","Percent of Total Billed Charges","neg_dollar:$20.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","20.33","52","","","Percent of Total Billed Charges","neg_dollar:$20.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","20.00","39.00",""
"DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24","A9270","HCPCS","60687-195-11","NDC","250","RC","","Facility","Outpatient","120","ME","1.69","1.69","","","","1.69","Fee Schedule","","","","","1.69","Fee Schedule","","","","","1.69","Fee Schedule","","","52","","1.69","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.45","86","","","Percent of Total Billed Charges","neg_dollar:$1.45","1.18","70","","","Percent of Total Billed Charges","neg_dollar:$1.18","","52","","1.69","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.26","75","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.45","86","","","Percent of Total Billed Charges","neg_dollar:$1.45","1.18","70","","","Percent of Total Billed Charges","neg_dollar:$1.18","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.69","150","","","Percent of Total Billed Charges","neg_dollar:$2.61;150% of Medicaid interim rate","1.35","80","","","Percent of Total Billed Charges","neg_dollar:$1.35;Percent of Total Billed Charges","1.55","92","","","Percent of Total Billed Charges","neg_dollar:$1.55","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.69","Fee Schedule","","1.00","1.00",""
"DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24","A9270","HCPCS","60687-195-11","NDC","637","RC","","Facility","Outpatient","120","ME","1.52","1.52","","","","1.52","Fee Schedule","","","","","1.52","Fee Schedule","101% of Medicare Fee Schedule","","","","1.52","Fee Schedule","","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.52","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.52","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.31","86","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.07","70","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.89;102% of Medicaid interim rate","1.14","75","","","Percent of Total Billed Charges","neg_dollar:$1.14","1.31","86","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.07","70","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.87;103.5% of Medicaid interim rate","1.52","150","","","Percent of Total Billed Charges","neg_dollar:$2.36;150% of Medicaid interim rate","1.22","80","","","Percent of Total Billed Charges","neg_dollar:$1.22;Percent of Total Billed Charges","1.40","92","","","Percent of Total Billed Charges","neg_dollar:$1.40","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","52","","","Percent of Total Billed Charges","neg_dollar:$0.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ACETAMINOPHEN-CODEINE 120-12 MG/5ML PO SOLN","A9270","HCPCS","00121-0504-16","NDC","637","RC","","Facility","Outpatient","5","ML","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"VANCOMYCIN HCL 125 MG PO CAPS","A9270","HCPCS","42494-450-20","NDC","250","RC","","Facility","Outpatient","1","EA","3.19","3.19","","","","3.19","Fee Schedule","","","","","3.19","Fee Schedule","","","","","3.19","Fee Schedule","","","52","","3.19","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.66","52","","","Percent of Total Billed Charges","neg_dollar:$1.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.66","52","","","Percent of Total Billed Charges","neg_dollar:$1.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.75","86","","","Percent of Total Billed Charges","neg_dollar:$2.75","2.23","70","","","Percent of Total Billed Charges","neg_dollar:$2.23","","52","","3.19","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.87;102% of Medicaid interim rate","2.39","75","","","Percent of Total Billed Charges","neg_dollar:$2.39","2.75","86","","","Percent of Total Billed Charges","neg_dollar:$2.75","2.23","70","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.82;103.5% of Medicaid interim rate","3.19","150","","","Percent of Total Billed Charges","neg_dollar:$4.94;150% of Medicaid interim rate","2.55","80","","","Percent of Total Billed Charges","neg_dollar:$2.55;Percent of Total Billed Charges","2.94","92","","","Percent of Total Billed Charges","neg_dollar:$2.94","1.66","52","","","Percent of Total Billed Charges","neg_dollar:$1.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.19","Fee Schedule","","1.00","3.00",""
"VANCOMYCIN HCL 125 MG PO CAPS","A9270","HCPCS","42494-450-20","NDC","637","RC","","Facility","Outpatient","1","EA","3.25","3.25","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","101% of Medicare Fee Schedule","","","","3.25","Fee Schedule","","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.90;102% of Medicaid interim rate","2.43","75","","","Percent of Total Billed Charges","neg_dollar:$2.43","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.85;103.5% of Medicaid interim rate","3.25","150","","","Percent of Total Billed Charges","neg_dollar:$5.02;150% of Medicaid interim rate","2.60","80","","","Percent of Total Billed Charges","neg_dollar:$2.60;Percent of Total Billed Charges","2.99","92","","","Percent of Total Billed Charges","neg_dollar:$2.99","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"CALCIUM CARBONATE 1250 (500 CA) MG PO CHEW","A9270","HCPCS","50268-149-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.22","1.22","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","","","52","","1.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","","52","","1.22","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% of Medicaid interim rate","0.92","75","","","Percent of Total Billed Charges","neg_dollar:$0.92","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;103.5% of Medicaid interim rate","1.22","150","","","Percent of Total Billed Charges","neg_dollar:$1.89;150% of Medicaid interim rate","0.98","80","","","Percent of Total Billed Charges","neg_dollar:$0.98;Percent of Total Billed Charges","1.13","92","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.22","Fee Schedule","","1.00","1.00",""
"CALCIUM CARBONATE 1250 (500 CA) MG PO CHEW","A9270","HCPCS","50268-149-13","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"CALCIUM CARBONATE 1250 (500 CA) MG PO CHEW","A9270","HCPCS","50268-149-11","NDC","637","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"NICOTINE 14 MG/24HR TD PT24","A9270","HCPCS","00536-5895-88","NDC","250","RC","","Facility","Outpatient","1","EA","3.10","3.10","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","","","52","","3.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","","52","","3.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% of Medicaid interim rate","2.32","75","","","Percent of Total Billed Charges","neg_dollar:$2.32","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","1.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.76;103.5% of Medicaid interim rate","3.10","150","","","Percent of Total Billed Charges","neg_dollar:$4.79;150% of Medicaid interim rate","2.48","80","","","Percent of Total Billed Charges","neg_dollar:$2.48;Percent of Total Billed Charges","2.85","92","","","Percent of Total Billed Charges","neg_dollar:$2.85","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.10","Fee Schedule","","1.00","3.00",""
"MORPHINE SULFATE 15 MG PO TABS","A9270","HCPCS","00054-0235-24","NDC","250","RC","","Facility","Outpatient","1","EA","1.95","1.95","","","","1.95","Fee Schedule","","","","","1.95","Fee Schedule","","","","","1.95","Fee Schedule","","","52","","1.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","52","","","Percent of Total Billed Charges","neg_dollar:$1.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","52","","","Percent of Total Billed Charges","neg_dollar:$1.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.67","86","","","Percent of Total Billed Charges","neg_dollar:$1.67","1.36","70","","","Percent of Total Billed Charges","neg_dollar:$1.36","","52","","1.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;102% of Medicaid interim rate","1.46","75","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.67","86","","","Percent of Total Billed Charges","neg_dollar:$1.67","1.36","70","","","Percent of Total Billed Charges","neg_dollar:$1.36","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;103.5% of Medicaid interim rate","1.95","150","","","Percent of Total Billed Charges","neg_dollar:$3.01;150% of Medicaid interim rate","1.56","80","","","Percent of Total Billed Charges","neg_dollar:$1.56;Percent of Total Billed Charges","1.79","92","","","Percent of Total Billed Charges","neg_dollar:$1.79","1.01","52","","","Percent of Total Billed Charges","neg_dollar:$1.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.95","Fee Schedule","","1.00","1.00",""
"MORPHINE SULFATE ER 15 MG PO TBCR","A9270","HCPCS","00406-8315-23","NDC","250","RC","","Facility","Outpatient","1","EA","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","","52","","1.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.70","Fee Schedule","","1.00","1.00",""
"MORPHINE SULFATE ER 15 MG PO TBCR","A9270","HCPCS","00406-8315-23","NDC","637","RC","","Facility","Outpatient","1","EA","1.51","1.51","","","","1.51","Fee Schedule","","","","","1.51","Fee Schedule","101% of Medicare Fee Schedule","","","","1.51","Fee Schedule","","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","86","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.06","70","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.89;102% of Medicaid interim rate","1.13","75","","","Percent of Total Billed Charges","neg_dollar:$1.13","1.30","86","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.06","70","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.86;103.5% of Medicaid interim rate","1.51","150","","","Percent of Total Billed Charges","neg_dollar:$2.34;150% of Medicaid interim rate","1.21","80","","","Percent of Total Billed Charges","neg_dollar:$1.21;Percent of Total Billed Charges","1.39","92","","","Percent of Total Billed Charges","neg_dollar:$1.39","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MIRTAZAPINE 15 MG PO TABS","A9270","HCPCS","68084-119-11","NDC","637","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MIRTAZAPINE 15 MG PO TABS","A9270","HCPCS","68084-119-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"QUETIAPINE FUMARATE ER 150 MG PO TB24","A9270","HCPCS","50228-381-60","NDC","250","RC","","Facility","Outpatient","1","EA","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","","52","","1.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.15","Fee Schedule","","1.00","1.00",""
"BUPROPION HCL ER (XL) 150 MG PO TB24","A9270","HCPCS","00904-7084-04","NDC","250","RC","","Facility","Outpatient","1","EA","2.60","2.60","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","52","","2.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","","52","","2.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.52;102% of Medicaid interim rate","1.95","75","","","Percent of Total Billed Charges","neg_dollar:$1.95","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","1.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.48;103.5% of Medicaid interim rate","2.60","150","","","Percent of Total Billed Charges","neg_dollar:$4.01;150% of Medicaid interim rate","2.08","80","","","Percent of Total Billed Charges","neg_dollar:$2.08;Percent of Total Billed Charges","2.39","92","","","Percent of Total Billed Charges","neg_dollar:$2.39","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.60","Fee Schedule","","1.00","2.00",""
"IRBESARTAN 150 MG PO TABS","A9270","HCPCS","31722-730-90","NDC","250","RC","","Facility","Outpatient","1","EA","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","","52","","1.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.45","Fee Schedule","","1.00","1.00",""
"BUPROPION HCL ER (XL) 150 MG PO TB24","A9270","HCPCS","60687-782-11","NDC","250","RC","","Facility","Outpatient","1","EA","3.25","3.25","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","","","52","","3.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","","52","","3.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.90;102% of Medicaid interim rate","2.43","75","","","Percent of Total Billed Charges","neg_dollar:$2.43","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.85;103.5% of Medicaid interim rate","3.25","150","","","Percent of Total Billed Charges","neg_dollar:$5.02;150% of Medicaid interim rate","2.60","80","","","Percent of Total Billed Charges","neg_dollar:$2.60;Percent of Total Billed Charges","2.99","92","","","Percent of Total Billed Charges","neg_dollar:$2.99","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.25","Fee Schedule","","1.00","3.00",""
"BUPROPION HCL ER (SR) 150 MG PO TB12","A9270","HCPCS","68084-708-95","NDC","250","RC","","Facility","Outpatient","1","EA","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","","52","","1.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.75","Fee Schedule","","1.00","1.00",""
"CLINDAMYCIN HCL 150 MG PO CAPS","A9270","HCPCS","68084-243-01","NDC","637","RC","","Facility","Outpatient","1","EA","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","101% of Medicare Fee Schedule","","","","1.05","Fee Schedule","","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BUPROPION HCL ER (XL) 150 MG PO TB24","A9270","HCPCS","00904-7084-04","NDC","637","RC","","Facility","Outpatient","1","EA","2.43","2.43","","","","2.43","Fee Schedule","","","","","2.43","Fee Schedule","101% of Medicare Fee Schedule","","","","2.43","Fee Schedule","","1.26","52","","","Percent of Total Billed Charges","neg_dollar:$1.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.09","86","","","Percent of Total Billed Charges","neg_dollar:$2.09","1.70","70","","","Percent of Total Billed Charges","neg_dollar:$1.70","1.26","52","","","Percent of Total Billed Charges","neg_dollar:$1.26;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.42;102% of Medicaid interim rate","1.82","75","","","Percent of Total Billed Charges","neg_dollar:$1.82","2.09","86","","","Percent of Total Billed Charges","neg_dollar:$2.09","1.70","70","","","Percent of Total Billed Charges","neg_dollar:$1.70","1.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.38;103.5% of Medicaid interim rate","2.43","150","","","Percent of Total Billed Charges","neg_dollar:$3.76;150% of Medicaid interim rate","1.94","80","","","Percent of Total Billed Charges","neg_dollar:$1.94;Percent of Total Billed Charges","2.23","92","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.26","52","","","Percent of Total Billed Charges","neg_dollar:$1.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.26","52","","","Percent of Total Billed Charges","neg_dollar:$1.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"IRBESARTAN 150 MG PO TABS","A9270","HCPCS","31722-730-90","NDC","637","RC","","Facility","Outpatient","1","EA","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","101% of Medicare Fee Schedule","","","","1.45","Fee Schedule","","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BUPROPION HCL ER (SR) 150 MG PO TB12","A9270","HCPCS","68084-708-95","NDC","637","RC","","Facility","Outpatient","1","EA","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","101% of Medicare Fee Schedule","","","","1.75","Fee Schedule","","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FENOFIBRATE 160 MG PO TABS","A9270","HCPCS","27241-117-03","NDC","637","RC","","Facility","Outpatient","1","EA","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","101% of Medicare Fee Schedule","","","","1.50","Fee Schedule","","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.31;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"POLYETHYLENE GLYCOL 3350 17 G PO PACK","A9270","HCPCS","00904-6931-86","NDC","250","RC","","Facility","Outpatient","17","GM","2.80","2.80","","","","2.80","Fee Schedule","","","","","2.80","Fee Schedule","","","","","2.80","Fee Schedule","","","52","","2.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.40","86","","","Percent of Total Billed Charges","neg_dollar:$2.40","1.96","70","","","Percent of Total Billed Charges","neg_dollar:$1.96","","52","","2.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.64;102% of Medicaid interim rate","2.10","75","","","Percent of Total Billed Charges","neg_dollar:$2.10","2.40","86","","","Percent of Total Billed Charges","neg_dollar:$2.40","1.96","70","","","Percent of Total Billed Charges","neg_dollar:$1.96","1.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.59;103.5% of Medicaid interim rate","2.80","150","","","Percent of Total Billed Charges","neg_dollar:$4.33;150% of Medicaid interim rate","2.24","80","","","Percent of Total Billed Charges","neg_dollar:$2.24;Percent of Total Billed Charges","2.57","92","","","Percent of Total Billed Charges","neg_dollar:$2.57","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.80","Fee Schedule","","1.00","2.00",""
"POLYETHYLENE GLYCOL 3350 PO POWD","A9270","HCPCS","68001-607-55","NDC","250","RC","","Facility","Outpatient","17","GM","16.55","16.55","","","","16.55","Fee Schedule","","","","","16.55","Fee Schedule","","","","","16.55","Fee Schedule","","","52","","16.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.60","52","","","Percent of Total Billed Charges","neg_dollar:$8.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.60","52","","","Percent of Total Billed Charges","neg_dollar:$8.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.23","86","","","Percent of Total Billed Charges","neg_dollar:$14.23","11.58","70","","","Percent of Total Billed Charges","neg_dollar:$11.58","","52","","16.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.72;102% of Medicaid interim rate","12.41","75","","","Percent of Total Billed Charges","neg_dollar:$12.41","14.23","86","","","Percent of Total Billed Charges","neg_dollar:$14.23","11.58","70","","","Percent of Total Billed Charges","neg_dollar:$11.58","9.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.43;103.5% of Medicaid interim rate","16.55","150","","","Percent of Total Billed Charges","neg_dollar:$25.58;150% of Medicaid interim rate","13.24","80","","","Percent of Total Billed Charges","neg_dollar:$13.24;Percent of Total Billed Charges","15.22","92","","","Percent of Total Billed Charges","neg_dollar:$15.22","8.60","52","","","Percent of Total Billed Charges","neg_dollar:$8.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","16.55","Fee Schedule","","8.00","16.00",""
"POLYETHYLENE GLYCOL 3350 17 G PO PACK","A9270","HCPCS","00904-6931-86","NDC","637","RC","","Facility","Outpatient","17","GM","2.84","2.84","","","","2.84","Fee Schedule","","","","","2.84","Fee Schedule","101% of Medicare Fee Schedule","","","","2.84","Fee Schedule","","1.47","52","","","Percent of Total Billed Charges","neg_dollar:$1.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.84","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.84","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.44","86","","","Percent of Total Billed Charges","neg_dollar:$2.44","1.99","70","","","Percent of Total Billed Charges","neg_dollar:$1.99","1.47","52","","","Percent of Total Billed Charges","neg_dollar:$1.47;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.67;102% of Medicaid interim rate","2.13","75","","","Percent of Total Billed Charges","neg_dollar:$2.13","2.44","86","","","Percent of Total Billed Charges","neg_dollar:$2.44","1.99","70","","","Percent of Total Billed Charges","neg_dollar:$1.99","1.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.62;103.5% of Medicaid interim rate","2.84","150","","","Percent of Total Billed Charges","neg_dollar:$4.39;150% of Medicaid interim rate","2.27","80","","","Percent of Total Billed Charges","neg_dollar:$2.27;Percent of Total Billed Charges","2.61","92","","","Percent of Total Billed Charges","neg_dollar:$2.61","1.47","52","","","Percent of Total Billed Charges","neg_dollar:$1.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.47","52","","","Percent of Total Billed Charges","neg_dollar:$1.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"TIOTROPIUM BROMIDE MONOHYDRATE 18 MCG IN CAPS","A9270","HCPCS","00597-0075-75","NDC","637","RC","","Facility","Outpatient","1","EA","122.10","122.10","","","","122.10","Fee Schedule","","","","","122.10","Fee Schedule","101% of Medicare Fee Schedule","","","","122.10","Fee Schedule","","63.49","52","","","Percent of Total Billed Charges","neg_dollar:$63.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","122.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","122.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","105.00","86","","","Percent of Total Billed Charges","neg_dollar:$105","85.46","70","","","Percent of Total Billed Charges","neg_dollar:$85.46","63.49","52","","","Percent of Total Billed Charges","neg_dollar:$63.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","71.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.73;102% of Medicaid interim rate","91.57","75","","","Percent of Total Billed Charges","neg_dollar:$91.57","105.00","86","","","Percent of Total Billed Charges","neg_dollar:$105","85.46","70","","","Percent of Total Billed Charges","neg_dollar:$85.46","69.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$69.59;103.5% of Medicaid interim rate","122.10","150","","","Percent of Total Billed Charges","neg_dollar:$188.77;150% of Medicaid interim rate","97.68","80","","","Percent of Total Billed Charges","neg_dollar:$97.68;Percent of Total Billed Charges","112.33","92","","","Percent of Total Billed Charges","neg_dollar:$112.33","63.49","52","","","Percent of Total Billed Charges","neg_dollar:$63.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","63.49","52","","","Percent of Total Billed Charges","neg_dollar:$63.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","63.00","122.00",""
"DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24","A9270","HCPCS","60687-206-11","NDC","250","RC","","Facility","Outpatient","180","ME","1.65","1.65","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.42","86","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","","52","","1.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.97;102% of Medicaid interim rate","1.24","75","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.42","86","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.65","150","","","Percent of Total Billed Charges","neg_dollar:$2.55;150% of Medicaid interim rate","1.32","80","","","Percent of Total Billed Charges","neg_dollar:$1.32;Percent of Total Billed Charges","1.52","92","","","Percent of Total Billed Charges","neg_dollar:$1.52","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.65","Fee Schedule","","1.00","1.00",""
"DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24","A9270","HCPCS","60687-206-11","NDC","637","RC","","Facility","Outpatient","180","ME","2","2.00","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"ENEMA DISPOSABLE 19-7 GM/118ML RE ENEM","A9270","HCPCS","00536-7415-51","NDC","250","RC","","Facility","Outpatient","1","EA","2.80","2.80","","","","2.80","Fee Schedule","","","","","2.80","Fee Schedule","","","","","2.80","Fee Schedule","","","52","","2.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.40","86","","","Percent of Total Billed Charges","neg_dollar:$2.40","1.95","70","","","Percent of Total Billed Charges","neg_dollar:$1.95","","52","","2.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.64;102% of Medicaid interim rate","2.09","75","","","Percent of Total Billed Charges","neg_dollar:$2.09","2.40","86","","","Percent of Total Billed Charges","neg_dollar:$2.40","1.95","70","","","Percent of Total Billed Charges","neg_dollar:$1.95","1.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.59;103.5% of Medicaid interim rate","2.80","150","","","Percent of Total Billed Charges","neg_dollar:$4.32;150% of Medicaid interim rate","2.23","80","","","Percent of Total Billed Charges","neg_dollar:$2.23;Percent of Total Billed Charges","2.57","92","","","Percent of Total Billed Charges","neg_dollar:$2.57","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.80","Fee Schedule","","1.00","2.00",""
"ENEMA DISPOSABLE 19-7 GM/118ML RE ENEM","A9270","HCPCS","00536-7415-51","NDC","637","RC","","Facility","Outpatient","1","EA","2.80","2.80","","","","2.80","Fee Schedule","","","","","2.80","Fee Schedule","101% of Medicare Fee Schedule","","","","2.80","Fee Schedule","","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.40","86","","","Percent of Total Billed Charges","neg_dollar:$2.40","1.95","70","","","Percent of Total Billed Charges","neg_dollar:$1.95","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.64;102% of Medicaid interim rate","2.09","75","","","Percent of Total Billed Charges","neg_dollar:$2.09","2.40","86","","","Percent of Total Billed Charges","neg_dollar:$2.40","1.95","70","","","Percent of Total Billed Charges","neg_dollar:$1.95","1.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.59;103.5% of Medicaid interim rate","2.80","150","","","Percent of Total Billed Charges","neg_dollar:$4.32;150% of Medicaid interim rate","2.23","80","","","Percent of Total Billed Charges","neg_dollar:$2.23;Percent of Total Billed Charges","2.57","92","","","Percent of Total Billed Charges","neg_dollar:$2.57","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.45","52","","","Percent of Total Billed Charges","neg_dollar:$1.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"ENEMA DISPOSABLE 19-7 GM/118ML RE ENEM","A9270","HCPCS","49348-186-20","NDC","637","RC","","Facility","Outpatient","1","EA","2.30","2.30","","","","2.30","Fee Schedule","","","","","2.30","Fee Schedule","101% of Medicare Fee Schedule","","","","2.30","Fee Schedule","","1.19","52","","","Percent of Total Billed Charges","neg_dollar:$1.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.97","86","","","Percent of Total Billed Charges","neg_dollar:$1.97","1.60","70","","","Percent of Total Billed Charges","neg_dollar:$1.60","1.19","52","","","Percent of Total Billed Charges","neg_dollar:$1.19;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% of Medicaid interim rate","1.72","75","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.97","86","","","Percent of Total Billed Charges","neg_dollar:$1.97","1.60","70","","","Percent of Total Billed Charges","neg_dollar:$1.60","1.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.31;103.5% of Medicaid interim rate","2.30","150","","","Percent of Total Billed Charges","neg_dollar:$3.55;150% of Medicaid interim rate","1.83","80","","","Percent of Total Billed Charges","neg_dollar:$1.83;Percent of Total Billed Charges","2.11","92","","","Percent of Total Billed Charges","neg_dollar:$2.11","1.19","52","","","Percent of Total Billed Charges","neg_dollar:$1.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.19","52","","","Percent of Total Billed Charges","neg_dollar:$1.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"LIDOCAINE VISCOUS HCL 2 % MT SOLN","A9270","HCPCS","00121-4950-15","NDC","250","RC","","Facility","Outpatient","1","EA","7.96","7.96","","","","7.96","Fee Schedule","","","","","7.96","Fee Schedule","","","","","7.96","Fee Schedule","","","52","","7.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.14","52","","","Percent of Total Billed Charges","neg_dollar:$4.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.14","52","","","Percent of Total Billed Charges","neg_dollar:$4.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.85","86","","","Percent of Total Billed Charges","neg_dollar:$6.85","5.57","70","","","Percent of Total Billed Charges","neg_dollar:$5.57","","52","","7.96","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","4.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.68;102% of Medicaid interim rate","5.97","75","","","Percent of Total Billed Charges","neg_dollar:$5.97","6.85","86","","","Percent of Total Billed Charges","neg_dollar:$6.85","5.57","70","","","Percent of Total Billed Charges","neg_dollar:$5.57","4.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.54;103.5% of Medicaid interim rate","7.96","150","","","Percent of Total Billed Charges","neg_dollar:$12.31;150% of Medicaid interim rate","6.37","80","","","Percent of Total Billed Charges","neg_dollar:$6.37;Percent of Total Billed Charges","7.32","92","","","Percent of Total Billed Charges","neg_dollar:$7.32","4.14","52","","","Percent of Total Billed Charges","neg_dollar:$4.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","7.96","Fee Schedule","","4.00","7.00",""
"HYDROMORPHONE HCL 2 MG PO TABS","A9270","HCPCS","42858-301-25","NDC","250","RC","","Facility","Outpatient","1","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"DIAZEPAM 2 MG PO TABS","A9270","HCPCS","51079-284-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"WARFARIN SODIUM 2 MG PO TABS","A9270","HCPCS","00832-1212-89","NDC","250","RC","","Facility","Outpatient","1","ME","1.22","1.22","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","","","52","","1.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","","52","","1.22","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% of Medicaid interim rate","0.92","75","","","Percent of Total Billed Charges","neg_dollar:$0.92","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;103.5% of Medicaid interim rate","1.22","150","","","Percent of Total Billed Charges","neg_dollar:$1.89;150% of Medicaid interim rate","0.98","80","","","Percent of Total Billed Charges","neg_dollar:$0.98;Percent of Total Billed Charges","1.12","92","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.22","Fee Schedule","","1.00","1.00",""
"LOPERAMIDE HCL 2 MG PO CAPS","A9270","HCPCS","60687-229-11","NDC","250","RC","","Facility","Outpatient","1","ME","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","","52","","2.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.05","Fee Schedule","","1.00","2.00",""
"MUPIROCIN 2 % EX OINT","A9270","HCPCS","68462-180-22","NDC","250","RC","","Facility","Outpatient","1","EA","20.40","20.40","","","","20.40","Fee Schedule","","","","","20.40","Fee Schedule","","","","","20.40","Fee Schedule","","","52","","20.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.54","86","","","Percent of Total Billed Charges","neg_dollar:$17.54","14.27","70","","","Percent of Total Billed Charges","neg_dollar:$14.27","","52","","20.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","11.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.98;102% of Medicaid interim rate","15.29","75","","","Percent of Total Billed Charges","neg_dollar:$15.29","17.54","86","","","Percent of Total Billed Charges","neg_dollar:$17.54","14.27","70","","","Percent of Total Billed Charges","neg_dollar:$14.27","11.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.62;103.5% of Medicaid interim rate","20.40","150","","","Percent of Total Billed Charges","neg_dollar:$31.53;150% of Medicaid interim rate","16.32","80","","","Percent of Total Billed Charges","neg_dollar:$16.32;Percent of Total Billed Charges","18.76","92","","","Percent of Total Billed Charges","neg_dollar:$18.76","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","20.40","Fee Schedule","","10.00","20.00",""
"GLIMEPIRIDE 2 MG PO TABS","A9270","HCPCS","68084-326-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","86","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","","52","","1.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.99","86","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.78;150% of Medicaid interim rate","0.92","80","","","Percent of Total Billed Charges","neg_dollar:$0.92;Percent of Total Billed Charges","1.06","92","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.15","Fee Schedule","","1.00","1.00",""
"NITROGLYCERIN 2 % TD OINT","A9270","HCPCS","00281-0326-08","NDC","637","RC","","Facility","Outpatient","1","EA","2.50","2.50","","","","2.50","Fee Schedule","","","","","2.50","Fee Schedule","101% of Medicare Fee Schedule","","","","2.50","Fee Schedule","","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.15","86","","","Percent of Total Billed Charges","neg_dollar:$2.15","1.75","70","","","Percent of Total Billed Charges","neg_dollar:$1.75","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.46;102% of Medicaid interim rate","1.87","75","","","Percent of Total Billed Charges","neg_dollar:$1.87","2.15","86","","","Percent of Total Billed Charges","neg_dollar:$2.15","1.75","70","","","Percent of Total Billed Charges","neg_dollar:$1.75","1.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.42;103.5% of Medicaid interim rate","2.50","150","","","Percent of Total Billed Charges","neg_dollar:$3.86;150% of Medicaid interim rate","2.00","80","","","Percent of Total Billed Charges","neg_dollar:$2;Percent of Total Billed Charges","2.30","92","","","Percent of Total Billed Charges","neg_dollar:$2.30","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"GLIMEPIRIDE 2 MG PO TABS","A9270","HCPCS","68084-326-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"WARFARIN SODIUM 2 MG PO TABS","A9270","HCPCS","00832-1212-89","NDC","637","RC","","Facility","Outpatient","1","ME","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","101% of Medicare Fee Schedule","","","","1.50","Fee Schedule","","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.31;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HYDROMORPHONE HCL 2 MG PO TABS","A9270","HCPCS","42858-301-25","NDC","637","RC","","Facility","Outpatient","1","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DIAZEPAM 2 MG PO TABS","A9270","HCPCS","51079-284-01","NDC","637","RC","","Facility","Outpatient","1","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE VISCOUS HCL 2 % MT SOLN","A9270","HCPCS","00121-4950-15","NDC","637","RC","","Facility","Outpatient","1","EA","8.07","8.07","","","","8.07","Fee Schedule","","","","","8.07","Fee Schedule","101% of Medicare Fee Schedule","","","","8.07","Fee Schedule","","4.19","52","","","Percent of Total Billed Charges","neg_dollar:$4.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.94","86","","","Percent of Total Billed Charges","neg_dollar:$6.94","5.65","70","","","Percent of Total Billed Charges","neg_dollar:$5.65","4.19","52","","","Percent of Total Billed Charges","neg_dollar:$4.19;105% Medicare Outpatient Cost to Charge Ratio of 52%","4.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.74;102% of Medicaid interim rate","6.05","75","","","Percent of Total Billed Charges","neg_dollar:$6.05","6.94","86","","","Percent of Total Billed Charges","neg_dollar:$6.94","5.65","70","","","Percent of Total Billed Charges","neg_dollar:$5.65","4.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.60;103.5% of Medicaid interim rate","8.07","150","","","Percent of Total Billed Charges","neg_dollar:$12.48;150% of Medicaid interim rate","6.46","80","","","Percent of Total Billed Charges","neg_dollar:$6.46;Percent of Total Billed Charges","7.42","92","","","Percent of Total Billed Charges","neg_dollar:$7.42","4.19","52","","","Percent of Total Billed Charges","neg_dollar:$4.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.19","52","","","Percent of Total Billed Charges","neg_dollar:$4.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","8.00",""
"LOPERAMIDE HCL 2 MG PO CAPS","A9270","HCPCS","60687-229-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.61","1.61","","","","1.61","Fee Schedule","","","","","1.61","Fee Schedule","101% of Medicare Fee Schedule","","","","1.61","Fee Schedule","","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.12","70","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.12","70","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.61","150","","","Percent of Total Billed Charges","neg_dollar:$2.49;150% of Medicaid interim rate","1.29","80","","","Percent of Total Billed Charges","neg_dollar:$1.29;Percent of Total Billed Charges","1.48","92","","","Percent of Total Billed Charges","neg_dollar:$1.48","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MUPIROCIN 2 % EX OINT","A9270","HCPCS","68462-180-22","NDC","637","RC","","Facility","Outpatient","1","EA","20.40","20.40","","","","20.40","Fee Schedule","","","","","20.40","Fee Schedule","101% of Medicare Fee Schedule","","","","20.40","Fee Schedule","","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.54","86","","","Percent of Total Billed Charges","neg_dollar:$17.54","14.27","70","","","Percent of Total Billed Charges","neg_dollar:$14.27","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","11.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.98;102% of Medicaid interim rate","15.29","75","","","Percent of Total Billed Charges","neg_dollar:$15.29","17.54","86","","","Percent of Total Billed Charges","neg_dollar:$17.54","14.27","70","","","Percent of Total Billed Charges","neg_dollar:$14.27","11.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.62;103.5% of Medicaid interim rate","20.40","150","","","Percent of Total Billed Charges","neg_dollar:$31.53;150% of Medicaid interim rate","16.32","80","","","Percent of Total Billed Charges","neg_dollar:$16.32;Percent of Total Billed Charges","18.76","92","","","Percent of Total Billed Charges","neg_dollar:$18.76","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.00","20.00",""
"LORAZEPAM 2 MG/ML PO CONC","A9270","HCPCS","00054-3532-44","NDC","637","RC","","Facility","Outpatient","1","ML","10.80","10.80","","","","10.80","Fee Schedule","","","","","10.80","Fee Schedule","101% of Medicare Fee Schedule","","","","10.80","Fee Schedule","","5.61","52","","","Percent of Total Billed Charges","neg_dollar:$5.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.28","86","","","Percent of Total Billed Charges","neg_dollar:$9.28","7.56","70","","","Percent of Total Billed Charges","neg_dollar:$7.56","5.61","52","","","Percent of Total Billed Charges","neg_dollar:$5.61;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.34;102% of Medicaid interim rate","8.10","75","","","Percent of Total Billed Charges","neg_dollar:$8.10","9.28","86","","","Percent of Total Billed Charges","neg_dollar:$9.28","7.56","70","","","Percent of Total Billed Charges","neg_dollar:$7.56","6.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.15;103.5% of Medicaid interim rate","10.80","150","","","Percent of Total Billed Charges","neg_dollar:$16.69;150% of Medicaid interim rate","8.64","80","","","Percent of Total Billed Charges","neg_dollar:$8.64;Percent of Total Billed Charges","9.93","92","","","Percent of Total Billed Charges","neg_dollar:$9.93","5.61","52","","","Percent of Total Billed Charges","neg_dollar:$5.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.61","52","","","Percent of Total Billed Charges","neg_dollar:$5.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"GLIPIZIDE ER 2.5 MG PO TB24","A9270","HCPCS","60687-768-11","NDC","250","RC","","Facility","Outpatient","1","ME","2.17","2.17","","","","2.17","Fee Schedule","","","","","2.17","Fee Schedule","","","","","2.17","Fee Schedule","","","52","","2.17","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.13","52","","","Percent of Total Billed Charges","neg_dollar:$1.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.13","52","","","Percent of Total Billed Charges","neg_dollar:$1.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.87","86","","","Percent of Total Billed Charges","neg_dollar:$1.87","1.52","70","","","Percent of Total Billed Charges","neg_dollar:$1.52","","52","","2.17","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.27;102% of Medicaid interim rate","1.63","75","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.87","86","","","Percent of Total Billed Charges","neg_dollar:$1.87","1.52","70","","","Percent of Total Billed Charges","neg_dollar:$1.52","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;103.5% of Medicaid interim rate","2.17","150","","","Percent of Total Billed Charges","neg_dollar:$3.36;150% of Medicaid interim rate","1.74","80","","","Percent of Total Billed Charges","neg_dollar:$1.74;Percent of Total Billed Charges","2.00","92","","","Percent of Total Billed Charges","neg_dollar:$2","1.13","52","","","Percent of Total Billed Charges","neg_dollar:$1.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.17","Fee Schedule","","1.00","2.00",""
"WARFARIN SODIUM 2.5 MG PO TABS","A9270","HCPCS","00832-1213-89","NDC","250","RC","","Facility","Outpatient","1","ME","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","","52","","1.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.31;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.50","Fee Schedule","","1.00","1.00",""
"HYDROCORTISONE (PERIANAL) 2.5 % EX CREA","A9270","HCPCS","62559-431-30","NDC","250","RC","","Facility","Outpatient","1","EA","86.75","86.75","","","","86.75","Fee Schedule","","","","","86.75","Fee Schedule","","","","","86.75","Fee Schedule","","","52","","86.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.11","52","","","Percent of Total Billed Charges","neg_dollar:$45.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.11","52","","","Percent of Total Billed Charges","neg_dollar:$45.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","74.60","86","","","Percent of Total Billed Charges","neg_dollar:$74.60","60.72","70","","","Percent of Total Billed Charges","neg_dollar:$60.72","","52","","86.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","50.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.96;102% of Medicaid interim rate","65.06","75","","","Percent of Total Billed Charges","neg_dollar:$65.06","74.60","86","","","Percent of Total Billed Charges","neg_dollar:$74.60","60.72","70","","","Percent of Total Billed Charges","neg_dollar:$60.72","49.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$49.44;103.5% of Medicaid interim rate","86.75","150","","","Percent of Total Billed Charges","neg_dollar:$134.11;150% of Medicaid interim rate","69.40","80","","","Percent of Total Billed Charges","neg_dollar:$69.40;Percent of Total Billed Charges","79.81","92","","","Percent of Total Billed Charges","neg_dollar:$79.81","45.11","52","","","Percent of Total Billed Charges","neg_dollar:$45.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","86.75","Fee Schedule","","45.00","86.00",""
"GLIPIZIDE ER 2.5 MG PO TB24","A9270","HCPCS","60687-480-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.61","1.61","","","","1.61","Fee Schedule","","","","","1.61","Fee Schedule","","","","","1.61","Fee Schedule","","","52","","1.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.12","70","","","Percent of Total Billed Charges","neg_dollar:$1.12","","52","","1.61","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;102% of Medicaid interim rate","1.21","75","","","Percent of Total Billed Charges","neg_dollar:$1.21","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.12","70","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.92;103.5% of Medicaid interim rate","1.61","150","","","Percent of Total Billed Charges","neg_dollar:$2.49;150% of Medicaid interim rate","1.29","80","","","Percent of Total Billed Charges","neg_dollar:$1.29;Percent of Total Billed Charges","1.48","92","","","Percent of Total Billed Charges","neg_dollar:$1.48","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.61","Fee Schedule","","1.00","1.00",""
"WARFARIN SODIUM 2.5 MG PO TABS","A9270","HCPCS","00832-1213-01","NDC","637","RC","","Facility","Outpatient","1","ME","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","101% of Medicare Fee Schedule","","","","1.50","Fee Schedule","","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.31;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"GLIPIZIDE ER 2.5 MG PO TB24","A9270","HCPCS","60687-768-11","NDC","637","RC","","Facility","Outpatient","1","ME","2.64","2.64","","","","2.64","Fee Schedule","","","","","2.64","Fee Schedule","101% of Medicare Fee Schedule","","","","2.64","Fee Schedule","","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.27","86","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.84","70","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.55;102% of Medicaid interim rate","1.98","75","","","Percent of Total Billed Charges","neg_dollar:$1.98","2.27","86","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.84","70","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.50;103.5% of Medicaid interim rate","2.64","150","","","Percent of Total Billed Charges","neg_dollar:$4.08;150% of Medicaid interim rate","2.11","80","","","Percent of Total Billed Charges","neg_dollar:$2.11;Percent of Total Billed Charges","2.42","92","","","Percent of Total Billed Charges","neg_dollar:$2.42","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","52","","","Percent of Total Billed Charges","neg_dollar:$1.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"WARFARIN SODIUM 2.5 MG PO TABS","A9270","HCPCS","00832-1213-89","NDC","637","RC","","Facility","Outpatient","1","ME","1.32","1.32","","","","1.32","Fee Schedule","","","","","1.32","Fee Schedule","101% of Medicare Fee Schedule","","","","1.32","Fee Schedule","","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.13","86","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","70","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% of Medicaid interim rate","0.99","75","","","Percent of Total Billed Charges","neg_dollar:$0.99","1.13","86","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","70","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.75;103.5% of Medicaid interim rate","1.32","150","","","Percent of Total Billed Charges","neg_dollar:$2.04;150% of Medicaid interim rate","1.06","80","","","Percent of Total Billed Charges","neg_dollar:$1.06;Percent of Total Billed Charges","1.21","92","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"GLIPIZIDE ER 2.5 MG PO TB24","A9270","HCPCS","60687-480-11","NDC","637","RC","","Facility","Outpatient","1","ME","2.40","2.40","","","","2.40","Fee Schedule","","","","","2.40","Fee Schedule","101% of Medicare Fee Schedule","","","","2.40","Fee Schedule","","1.24","52","","","Percent of Total Billed Charges","neg_dollar:$1.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.06","86","","","Percent of Total Billed Charges","neg_dollar:$2.06","1.68","70","","","Percent of Total Billed Charges","neg_dollar:$1.68","1.24","52","","","Percent of Total Billed Charges","neg_dollar:$1.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.40;102% of Medicaid interim rate","1.79","75","","","Percent of Total Billed Charges","neg_dollar:$1.79","2.06","86","","","Percent of Total Billed Charges","neg_dollar:$2.06","1.68","70","","","Percent of Total Billed Charges","neg_dollar:$1.68","1.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.36;103.5% of Medicaid interim rate","2.40","150","","","Percent of Total Billed Charges","neg_dollar:$3.71;150% of Medicaid interim rate","1.92","80","","","Percent of Total Billed Charges","neg_dollar:$1.92;Percent of Total Billed Charges","2.20","92","","","Percent of Total Billed Charges","neg_dollar:$2.20","1.24","52","","","Percent of Total Billed Charges","neg_dollar:$1.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","52","","","Percent of Total Billed Charges","neg_dollar:$1.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"HYDROCORTISONE (PERIANAL) 2.5 % EX CREA","A9270","HCPCS","62559-431-30","NDC","637","RC","","Facility","Outpatient","1","EA","86.75","86.75","","","","86.75","Fee Schedule","","","","","86.75","Fee Schedule","101% of Medicare Fee Schedule","","","","86.75","Fee Schedule","","45.11","52","","","Percent of Total Billed Charges","neg_dollar:$45.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","86.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","86.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","74.60","86","","","Percent of Total Billed Charges","neg_dollar:$74.60","60.72","70","","","Percent of Total Billed Charges","neg_dollar:$60.72","45.11","52","","","Percent of Total Billed Charges","neg_dollar:$45.11;105% Medicare Outpatient Cost to Charge Ratio of 52%","50.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.96;102% of Medicaid interim rate","65.06","75","","","Percent of Total Billed Charges","neg_dollar:$65.06","74.60","86","","","Percent of Total Billed Charges","neg_dollar:$74.60","60.72","70","","","Percent of Total Billed Charges","neg_dollar:$60.72","49.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$49.44;103.5% of Medicaid interim rate","86.75","150","","","Percent of Total Billed Charges","neg_dollar:$134.11;150% of Medicaid interim rate","69.40","80","","","Percent of Total Billed Charges","neg_dollar:$69.40;Percent of Total Billed Charges","79.81","92","","","Percent of Total Billed Charges","neg_dollar:$79.81","45.11","52","","","Percent of Total Billed Charges","neg_dollar:$45.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.11","52","","","Percent of Total Billed Charges","neg_dollar:$45.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.00","86.00",""
"DULOXETINE HCL 20 MG PO CPEP","A9270","HCPCS","00002-3235-60","NDC","250","RC","","Facility","Outpatient","20","ME","11.05","11.05","","","","11.05","Fee Schedule","","","","","11.05","Fee Schedule","","","","","11.05","Fee Schedule","","","52","","11.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.74","52","","","Percent of Total Billed Charges","neg_dollar:$5.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.74","52","","","Percent of Total Billed Charges","neg_dollar:$5.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.50","86","","","Percent of Total Billed Charges","neg_dollar:$9.50","7.73","70","","","Percent of Total Billed Charges","neg_dollar:$7.73","","52","","11.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.49;102% of Medicaid interim rate","8.28","75","","","Percent of Total Billed Charges","neg_dollar:$8.28","9.50","86","","","Percent of Total Billed Charges","neg_dollar:$9.50","7.73","70","","","Percent of Total Billed Charges","neg_dollar:$7.73","6.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.29;103.5% of Medicaid interim rate","11.05","150","","","Percent of Total Billed Charges","neg_dollar:$17.08;150% of Medicaid interim rate","8.84","80","","","Percent of Total Billed Charges","neg_dollar:$8.84;Percent of Total Billed Charges","10.16","92","","","Percent of Total Billed Charges","neg_dollar:$10.16","5.74","52","","","Percent of Total Billed Charges","neg_dollar:$5.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","11.05","Fee Schedule","","5.00","11.00",""
"FAMOTIDINE 20 MG PO TABS","A9270","HCPCS","00904-7193-61","NDC","250","RC","","Facility","Outpatient","20","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"ESOMEPRAZOLE MAGNESIUM 20 MG PO CPDR","A9270","HCPCS","00573-2450-28","NDC","250","RC","","Facility","Outpatient","20","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"LISINOPRIL 20 MG PO TABS","A9270","HCPCS","00904-6799-61","NDC","250","RC","","Facility","Outpatient","20","ME","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","","52","","0.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% of Medicaid interim rate","0.63","75","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.31;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.85","Fee Schedule","","1.00","1.00",""
"FLUOXETINE HCL 20 MG PO CAPS","A9270","HCPCS","00904-7346-61","NDC","250","RC","","Facility","Outpatient","20","ME","0.74","0.74","","","","0.74","Fee Schedule","","","","","0.74","Fee Schedule","","","","","0.74","Fee Schedule","","","52","","0.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.38","52","","","Percent of Total Billed Charges","neg_dollar:$0.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.38","52","","","Percent of Total Billed Charges","neg_dollar:$0.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","86","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.51","70","","","Percent of Total Billed Charges","neg_dollar:$0.51","","52","","0.74","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.43;102% of Medicaid interim rate","0.55","75","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.63","86","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.51","70","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;103.5% of Medicaid interim rate","0.74","150","","","Percent of Total Billed Charges","neg_dollar:$1.14;150% of Medicaid interim rate","0.59","80","","","Percent of Total Billed Charges","neg_dollar:$0.59;Percent of Total Billed Charges","0.68","92","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.38","52","","","Percent of Total Billed Charges","neg_dollar:$0.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.74","Fee Schedule","","1.00","1.00",""
"MORPHINE SULFATE (CONCENTRATE) 20 MG/ML PO SOLN","A9270","HCPCS","00406-8003-30","NDC","250","RC","","Facility","Outpatient","1","UN","1.17","1.17","","","","1.17","Fee Schedule","","","","","1.17","Fee Schedule","","","","","1.17","Fee Schedule","","","52","","1.17","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","86","","","Percent of Total Billed Charges","neg_dollar:$1","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","","52","","1.17","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% of Medicaid interim rate","0.87","75","","","Percent of Total Billed Charges","neg_dollar:$0.87","1.00","86","","","Percent of Total Billed Charges","neg_dollar:$1","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.66;103.5% of Medicaid interim rate","1.17","150","","","Percent of Total Billed Charges","neg_dollar:$1.80;150% of Medicaid interim rate","0.93","80","","","Percent of Total Billed Charges","neg_dollar:$0.93;Percent of Total Billed Charges","1.07","92","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.17","Fee Schedule","","1.00","1.00",""
"CITALOPRAM HYDROBROMIDE 20 MG PO TABS","A9270","HCPCS","00904-6085-61","NDC","250","RC","","Facility","Outpatient","20","ME","0.82","0.82","","","","0.82","Fee Schedule","","","","","0.82","Fee Schedule","","","","","0.82","Fee Schedule","","","52","","0.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","52","","","Percent of Total Billed Charges","neg_dollar:$0.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","52","","","Percent of Total Billed Charges","neg_dollar:$0.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","86","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.58","70","","","Percent of Total Billed Charges","neg_dollar:$0.58","","52","","0.82","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% of Medicaid interim rate","0.62","75","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.71","86","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.58","70","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;103.5% of Medicaid interim rate","0.82","150","","","Percent of Total Billed Charges","neg_dollar:$1.28;150% of Medicaid interim rate","0.66","80","","","Percent of Total Billed Charges","neg_dollar:$0.66;Percent of Total Billed Charges","0.76","92","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.43","52","","","Percent of Total Billed Charges","neg_dollar:$0.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.82","Fee Schedule","","1.00","1.00",""
"FUROSEMIDE 20 MG PO TABS","A9270","HCPCS","00054-8297-25","NDC","250","RC","","Facility","Outpatient","20","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"PANTOPRAZOLE SODIUM 20 MG PO TBEC","A9270","HCPCS","60687-725-11","NDC","250","RC","","Facility","Outpatient","20","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"SIMVASTATIN 20 MG PO TABS","A9270","HCPCS","68084-512-01","NDC","250","RC","","Facility","Outpatient","20","ME","0.80","0.80","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","","","52","","0.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","","52","","0.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.60","75","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.80","150","","","Percent of Total Billed Charges","neg_dollar:$1.23;150% of Medicaid interim rate","0.64","80","","","Percent of Total Billed Charges","neg_dollar:$0.64;Percent of Total Billed Charges","0.73","92","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.80","Fee Schedule","","1.00","1.00",""
"HYDROCORTISONE 20 MG PO TABS","A9270","HCPCS","59762-0075-1","NDC","250","RC","","Facility","Outpatient","20","ME","1.65","1.65","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","","52","","1.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.23","75","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.65","150","","","Percent of Total Billed Charges","neg_dollar:$2.55;150% of Medicaid interim rate","1.32","80","","","Percent of Total Billed Charges","neg_dollar:$1.32;Percent of Total Billed Charges","1.51","92","","","Percent of Total Billed Charges","neg_dollar:$1.51","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.65","Fee Schedule","","1.00","1.00",""
"PRAVASTATIN SODIUM 20 MG PO TABS","A9270","HCPCS","60687-178-11","NDC","250","RC","","Facility","Outpatient","20","ME","1.85","1.85","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","","52","","1.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;103.5% of Medicaid interim rate","1.85","150","","","Percent of Total Billed Charges","neg_dollar:$2.86;150% of Medicaid interim rate","1.48","80","","","Percent of Total Billed Charges","neg_dollar:$1.48;Percent of Total Billed Charges","1.70","92","","","Percent of Total Billed Charges","neg_dollar:$1.70","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.85","Fee Schedule","","1.00","1.00",""
"FAMOTIDINE 20 MG PO TABS","A9270","HCPCS","63739-645-10","NDC","250","RC","","Facility","Outpatient","20","ME","0.69","0.69","","","","0.69","Fee Schedule","","","","","0.69","Fee Schedule","","","","","0.69","Fee Schedule","","","52","","0.69","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","52","","","Percent of Total Billed Charges","neg_dollar:$0.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","52","","","Percent of Total Billed Charges","neg_dollar:$0.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","86","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","70","","","Percent of Total Billed Charges","neg_dollar:$0.48","","52","","0.69","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% of Medicaid interim rate","0.52","75","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.59","86","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","70","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.39;103.5% of Medicaid interim rate","0.69","150","","","Percent of Total Billed Charges","neg_dollar:$1.07;150% of Medicaid interim rate","0.55","80","","","Percent of Total Billed Charges","neg_dollar:$0.55;Percent of Total Billed Charges","0.64","92","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.36","52","","","Percent of Total Billed Charges","neg_dollar:$0.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.69","Fee Schedule","","1.00","1.00",""
"SIMVASTATIN 20 MG PO TABS","A9270","HCPCS","68084-512-11","NDC","250","RC","","Facility","Outpatient","20","ME","0.93","0.93","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","52","","0.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","","52","","0.93","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% of Medicaid interim rate","0.69","75","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;103.5% of Medicaid interim rate","0.93","150","","","Percent of Total Billed Charges","neg_dollar:$1.44;150% of Medicaid interim rate","0.74","80","","","Percent of Total Billed Charges","neg_dollar:$0.74;Percent of Total Billed Charges","0.85","92","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.93","Fee Schedule","","1.00","1.00",""
"FAMOTIDINE 20 MG PO TABS","A9270","HCPCS","00904-7193-61","NDC","637","RC","","Facility","Outpatient","20","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FUROSEMIDE 20 MG PO TABS","A9270","HCPCS","00054-8297-25","NDC","637","RC","","Facility","Outpatient","20","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TORSEMIDE 20 MG PO TABS","A9270","HCPCS","50268-756-11","NDC","250","RC","","Facility","Outpatient","20","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% of Medicaid interim rate","0.79","75","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.63;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.97","92","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"PANTOPRAZOLE SODIUM 20 MG PO TBEC","A9270","HCPCS","60687-725-01","NDC","250","RC","","Facility","Outpatient","20","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"PANTOPRAZOLE SODIUM 20 MG PO TBEC","A9270","HCPCS","60687-585-11","NDC","250","RC","","Facility","Outpatient","20","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"LISINOPRIL 20 MG PO TABS","A9270","HCPCS","00904-6799-61","NDC","637","RC","","Facility","Outpatient","20","ME","0.66","0.66","","","","0.66","Fee Schedule","","","","","0.66","Fee Schedule","101% of Medicare Fee Schedule","","","","0.66","Fee Schedule","","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","86","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.46","70","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% of Medicaid interim rate","0.50","75","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.57","86","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.46","70","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.38;103.5% of Medicaid interim rate","0.66","150","","","Percent of Total Billed Charges","neg_dollar:$1.03;150% of Medicaid interim rate","0.53","80","","","Percent of Total Billed Charges","neg_dollar:$0.53;Percent of Total Billed Charges","0.61","92","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FLUOXETINE HCL 20 MG PO CAPS","A9270","HCPCS","00904-7346-61","NDC","637","RC","","Facility","Outpatient","20","ME","0.64","0.64","","","","0.64","Fee Schedule","","","","","0.64","Fee Schedule","101% of Medicare Fee Schedule","","","","0.64","Fee Schedule","","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.44","70","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% of Medicaid interim rate","0.48","75","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.44","70","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.36;103.5% of Medicaid interim rate","0.64","150","","","Percent of Total Billed Charges","neg_dollar:$0.98;150% of Medicaid interim rate","0.51","80","","","Percent of Total Billed Charges","neg_dollar:$0.51;Percent of Total Billed Charges","0.58","92","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PANTOPRAZOLE SODIUM 20 MG PO TBEC","A9270","HCPCS","60687-725-11","NDC","637","RC","","Facility","Outpatient","20","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HYDROCORTISONE 20 MG PO TABS","A9270","HCPCS","59762-0075-1","NDC","637","RC","","Facility","Outpatient","20","ME","1.65","1.65","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","101% of Medicare Fee Schedule","","","","1.65","Fee Schedule","","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.23","75","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.65","150","","","Percent of Total Billed Charges","neg_dollar:$2.55;150% of Medicaid interim rate","1.32","80","","","Percent of Total Billed Charges","neg_dollar:$1.32;Percent of Total Billed Charges","1.51","92","","","Percent of Total Billed Charges","neg_dollar:$1.51","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PRAVASTATIN SODIUM 20 MG PO TABS","A9270","HCPCS","60687-178-11","NDC","637","RC","","Facility","Outpatient","20","ME","1.67","1.67","","","","1.67","Fee Schedule","","","","","1.67","Fee Schedule","101% of Medicare Fee Schedule","","","","1.67","Fee Schedule","","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.43","86","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.17","70","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% of Medicaid interim rate","1.25","75","","","Percent of Total Billed Charges","neg_dollar:$1.25","1.43","86","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.17","70","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.95;103.5% of Medicaid interim rate","1.67","150","","","Percent of Total Billed Charges","neg_dollar:$2.58;150% of Medicaid interim rate","1.33","80","","","Percent of Total Billed Charges","neg_dollar:$1.33;Percent of Total Billed Charges","1.53","92","","","Percent of Total Billed Charges","neg_dollar:$1.53","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FAMOTIDINE 20 MG PO TABS","A9270","HCPCS","63739-645-10","NDC","637","RC","","Facility","Outpatient","20","ME","0.96","0.96","","","","0.96","Fee Schedule","","","","","0.96","Fee Schedule","101% of Medicare Fee Schedule","","","","0.96","Fee Schedule","","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","86","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.67","70","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% of Medicaid interim rate","0.72","75","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.83","86","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.67","70","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;103.5% of Medicaid interim rate","0.96","150","","","Percent of Total Billed Charges","neg_dollar:$1.49;150% of Medicaid interim rate","0.77","80","","","Percent of Total Billed Charges","neg_dollar:$0.77;Percent of Total Billed Charges","0.88","92","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PAROXETINE HCL 20 MG PO TABS","A9270","HCPCS","68084-045-11","NDC","637","RC","","Facility","Outpatient","20","ME","0.90","0.90","","","","0.90","Fee Schedule","","","","","0.90","Fee Schedule","101% of Medicare Fee Schedule","","","","0.90","Fee Schedule","","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% of Medicaid interim rate","0.67","75","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.90","150","","","Percent of Total Billed Charges","neg_dollar:$1.39;150% of Medicaid interim rate","0.72","80","","","Percent of Total Billed Charges","neg_dollar:$0.72;Percent of Total Billed Charges","0.82","92","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SIMVASTATIN 20 MG PO TABS","A9270","HCPCS","68084-512-11","NDC","637","RC","","Facility","Outpatient","20","ME","0.93","0.93","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","101% of Medicare Fee Schedule","","","","0.93","Fee Schedule","","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.70","75","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;103.5% of Medicaid interim rate","0.93","150","","","Percent of Total Billed Charges","neg_dollar:$1.44;150% of Medicaid interim rate","0.74","80","","","Percent of Total Billed Charges","neg_dollar:$0.74;Percent of Total Billed Charges","0.86","92","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CITALOPRAM HYDROBROMIDE 20 MG PO TABS","A9270","HCPCS","00904-6085-61","NDC","637","RC","","Facility","Outpatient","20","ME","0.69","0.69","","","","0.69","Fee Schedule","","","","","0.69","Fee Schedule","101% of Medicare Fee Schedule","","","","0.69","Fee Schedule","","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.69","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.69","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","86","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","70","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% of Medicaid interim rate","0.51","75","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.59","86","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","70","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.39;103.5% of Medicaid interim rate","0.69","150","","","Percent of Total Billed Charges","neg_dollar:$1.06;150% of Medicaid interim rate","0.55","80","","","Percent of Total Billed Charges","neg_dollar:$0.55;Percent of Total Billed Charges","0.63","92","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LOVASTATIN 20 MG PO TABS","A9270","HCPCS","68180-468-01","NDC","250","RC","","Facility","Outpatient","20","ME","0.86","0.86","","","","0.86","Fee Schedule","","","","","0.86","Fee Schedule","","","","","0.86","Fee Schedule","","","52","","0.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","86","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.60","70","","","Percent of Total Billed Charges","neg_dollar:$0.60","","52","","0.86","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% of Medicaid interim rate","0.64","75","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.74","86","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.60","70","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.49;103.5% of Medicaid interim rate","0.86","150","","","Percent of Total Billed Charges","neg_dollar:$1.33;150% of Medicaid interim rate","0.69","80","","","Percent of Total Billed Charges","neg_dollar:$0.69;Percent of Total Billed Charges","0.79","92","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.86","Fee Schedule","","1.00","1.00",""
"PANTOPRAZOLE SODIUM 20 MG PO TBEC","A9270","HCPCS","60687-585-11","NDC","637","RC","","Facility","Outpatient","20","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TORSEMIDE 20 MG PO TABS","A9270","HCPCS","50268-756-11","NDC","637","RC","","Facility","Outpatient","20","ME","1.06","1.06","","","","1.06","Fee Schedule","","","","","1.06","Fee Schedule","101% of Medicare Fee Schedule","","","","1.06","Fee Schedule","","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","86","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.74","70","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% of Medicaid interim rate","0.80","75","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.91","86","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.74","70","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;103.5% of Medicaid interim rate","1.06","150","","","Percent of Total Billed Charges","neg_dollar:$1.65;150% of Medicaid interim rate","0.85","80","","","Percent of Total Billed Charges","neg_dollar:$0.85;Percent of Total Billed Charges","0.98","92","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LOVASTATIN 20 MG PO TABS","A9270","HCPCS","68180-468-01","NDC","637","RC","","Facility","Outpatient","20","ME","0.98","0.98","","","","0.98","Fee Schedule","","","","","0.98","Fee Schedule","101% of Medicare Fee Schedule","","","","0.98","Fee Schedule","","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.84","86","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","70","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% of Medicaid interim rate","0.73","75","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.84","86","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","70","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;103.5% of Medicaid interim rate","0.98","150","","","Percent of Total Billed Charges","neg_dollar:$1.52;150% of Medicaid interim rate","0.78","80","","","Percent of Total Billed Charges","neg_dollar:$0.78;Percent of Total Billed Charges","0.90","92","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TAKE HOME PREDNISONE 20 MG PO TABS (QTY: FOUR)","A9270","HCPCS","09999-4101-12","NDC","253","RC","","Facility","Outpatient","1","EA","11.40","11.40","11.40","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","11.40","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.80","86","","","Percent of Total Billed Charges","neg_dollar:$9.80","7.97","70","","","Percent of Total Billed Charges","neg_dollar:$7.97","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.69;102% of Medicaid interim rate","8.55","75","","","Percent of Total Billed Charges","neg_dollar:$8.55","9.80","86","","","Percent of Total Billed Charges","neg_dollar:$9.80","7.97","70","","","Percent of Total Billed Charges","neg_dollar:$7.97","6.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.49;103.5% of Medicaid interim rate","11.40","150","","","Percent of Total Billed Charges","neg_dollar:$17.62;150% of Medicaid interim rate","9.12","80","","","Percent of Total Billed Charges","neg_dollar:$9.12;Percent of Total Billed Charges","10.48","92","","","Percent of Total Billed Charges","neg_dollar:$10.48","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","11.00",""
"POTASSIUM CHLORIDE 20 MEQ/15ML (10%) PO SOLN","A9270","HCPCS","60687-628-44","NDC","250","RC","","Facility","Outpatient","1","UN","25.27","25.27","","","","25.27","Fee Schedule","","","","","25.27","Fee Schedule","","","","","25.27","Fee Schedule","","","52","","25.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.14","52","","","Percent of Total Billed Charges","neg_dollar:$13.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.14","52","","","Percent of Total Billed Charges","neg_dollar:$13.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.73","86","","","Percent of Total Billed Charges","neg_dollar:$21.73","17.69","70","","","Percent of Total Billed Charges","neg_dollar:$17.69","","52","","25.27","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.84;102% of Medicaid interim rate","18.95","75","","","Percent of Total Billed Charges","neg_dollar:$18.95","21.73","86","","","Percent of Total Billed Charges","neg_dollar:$21.73","17.69","70","","","Percent of Total Billed Charges","neg_dollar:$17.69","14.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.40;103.5% of Medicaid interim rate","25.27","150","","","Percent of Total Billed Charges","neg_dollar:$39.07;150% of Medicaid interim rate","20.22","80","","","Percent of Total Billed Charges","neg_dollar:$20.22;Percent of Total Billed Charges","23.25","92","","","Percent of Total Billed Charges","neg_dollar:$23.25","13.14","52","","","Percent of Total Billed Charges","neg_dollar:$13.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.27","Fee Schedule","","13.00","25.00",""
"POTASSIUM CHLORIDE 20 MEQ/15ML (10%) PO SOLN","A9270","HCPCS","60687-628-71","NDC","250","RC","","Facility","Outpatient","1","UN","23.63","23.63","","","","23.63","Fee Schedule","","","","","23.63","Fee Schedule","","","","","23.63","Fee Schedule","","","52","","23.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.28","52","","","Percent of Total Billed Charges","neg_dollar:$12.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.28","52","","","Percent of Total Billed Charges","neg_dollar:$12.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.32","86","","","Percent of Total Billed Charges","neg_dollar:$20.32","16.54","70","","","Percent of Total Billed Charges","neg_dollar:$16.54","","52","","23.63","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.88;102% of Medicaid interim rate","17.72","75","","","Percent of Total Billed Charges","neg_dollar:$17.72","20.32","86","","","Percent of Total Billed Charges","neg_dollar:$20.32","16.54","70","","","Percent of Total Billed Charges","neg_dollar:$16.54","13.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.47;103.5% of Medicaid interim rate","23.63","150","","","Percent of Total Billed Charges","neg_dollar:$36.53;150% of Medicaid interim rate","18.90","80","","","Percent of Total Billed Charges","neg_dollar:$18.90;Percent of Total Billed Charges","21.74","92","","","Percent of Total Billed Charges","neg_dollar:$21.74","12.28","52","","","Percent of Total Billed Charges","neg_dollar:$12.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","23.63","Fee Schedule","","12.00","23.00",""
"POTASSIUM CHLORIDE 20 MEQ/15ML (10%) PO SOLN","A9270","HCPCS","60687-628-44","NDC","637","RC","","Facility","Outpatient","1","UN","29.65","29.65","","","","29.65","Fee Schedule","","","","","29.65","Fee Schedule","101% of Medicare Fee Schedule","","","","29.65","Fee Schedule","","15.41","52","","","Percent of Total Billed Charges","neg_dollar:$15.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","29.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","29.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","25.49","86","","","Percent of Total Billed Charges","neg_dollar:$25.49","20.75","70","","","Percent of Total Billed Charges","neg_dollar:$20.75","15.41","52","","","Percent of Total Billed Charges","neg_dollar:$15.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","17.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.41;102% of Medicaid interim rate","22.23","75","","","Percent of Total Billed Charges","neg_dollar:$22.23","25.49","86","","","Percent of Total Billed Charges","neg_dollar:$25.49","20.75","70","","","Percent of Total Billed Charges","neg_dollar:$20.75","16.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.90;103.5% of Medicaid interim rate","29.65","150","","","Percent of Total Billed Charges","neg_dollar:$45.84;150% of Medicaid interim rate","23.72","80","","","Percent of Total Billed Charges","neg_dollar:$23.72;Percent of Total Billed Charges","27.27","92","","","Percent of Total Billed Charges","neg_dollar:$27.27","15.41","52","","","Percent of Total Billed Charges","neg_dollar:$15.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.41","52","","","Percent of Total Billed Charges","neg_dollar:$15.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.00","29.00",""
"POTASSIUM CHLORIDE 20 MEQ/15ML (10%) PO SOLN","A9270","HCPCS","60687-628-71","NDC","637","RC","","Facility","Outpatient","1","UN","25.85","25.85","","","","25.85","Fee Schedule","","","","","25.85","Fee Schedule","101% of Medicare Fee Schedule","","","","25.85","Fee Schedule","","13.44","52","","","Percent of Total Billed Charges","neg_dollar:$13.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.23","86","","","Percent of Total Billed Charges","neg_dollar:$22.23","18.09","70","","","Percent of Total Billed Charges","neg_dollar:$18.09","13.44","52","","","Percent of Total Billed Charges","neg_dollar:$13.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","15.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.18;102% of Medicaid interim rate","19.38","75","","","Percent of Total Billed Charges","neg_dollar:$19.38","22.23","86","","","Percent of Total Billed Charges","neg_dollar:$22.23","18.09","70","","","Percent of Total Billed Charges","neg_dollar:$18.09","14.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.73;103.5% of Medicaid interim rate","25.85","150","","","Percent of Total Billed Charges","neg_dollar:$39.96;150% of Medicaid interim rate","20.68","80","","","Percent of Total Billed Charges","neg_dollar:$20.68;Percent of Total Billed Charges","23.78","92","","","Percent of Total Billed Charges","neg_dollar:$23.78","13.44","52","","","Percent of Total Billed Charges","neg_dollar:$13.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.44","52","","","Percent of Total Billed Charges","neg_dollar:$13.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","25.00",""
"IBUPROFEN 200 MG PO TABS","A9270","HCPCS","00904-7914-61","NDC","250","RC","","Facility","Outpatient","200","ME","1.01","1.01","","","","1.01","Fee Schedule","","","","","1.01","Fee Schedule","","","","","1.01","Fee Schedule","","","52","","1.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","","52","","1.01","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% of Medicaid interim rate","0.75","75","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.01","150","","","Percent of Total Billed Charges","neg_dollar:$1.56;150% of Medicaid interim rate","0.80","80","","","Percent of Total Billed Charges","neg_dollar:$0.80;Percent of Total Billed Charges","0.92","92","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.01","Fee Schedule","","1.00","1.00",""
"AMIODARONE HCL 200 MG PO TABS","A9270","HCPCS","63739-051-10","NDC","250","RC","","Facility","Outpatient","200","ME","1.12","1.12","","","","1.12","Fee Schedule","","","","","1.12","Fee Schedule","","","","","1.12","Fee Schedule","","","52","","1.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","","52","","1.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.66;102% of Medicaid interim rate","0.84","75","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;103.5% of Medicaid interim rate","1.12","150","","","Percent of Total Billed Charges","neg_dollar:$1.73;150% of Medicaid interim rate","0.90","80","","","Percent of Total Billed Charges","neg_dollar:$0.90;Percent of Total Billed Charges","1.03","92","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.12","Fee Schedule","","1.00","1.00",""
"CARBAMAZEPINE 200 MG PO TABS","A9270","HCPCS","00904-6172-61","NDC","250","RC","","Facility","Outpatient","200","ME","2.10","2.10","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","","52","","2.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% of Medicaid interim rate","1.57","75","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.19;103.5% of Medicaid interim rate","2.10","150","","","Percent of Total Billed Charges","neg_dollar:$3.24;150% of Medicaid interim rate","1.68","80","","","Percent of Total Billed Charges","neg_dollar:$1.68;Percent of Total Billed Charges","1.93","92","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.10","Fee Schedule","","1.00","2.00",""
"HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS","A9270","HCPCS","68084-269-11","NDC","250","RC","","Facility","Outpatient","200","ME","3.35","3.35","","","","3.35","Fee Schedule","","","","","3.35","Fee Schedule","","","","","3.35","Fee Schedule","","","52","","3.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.74","52","","","Percent of Total Billed Charges","neg_dollar:$1.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.74","52","","","Percent of Total Billed Charges","neg_dollar:$1.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","86","","","Percent of Total Billed Charges","neg_dollar:$2.88","2.34","70","","","Percent of Total Billed Charges","neg_dollar:$2.34","","52","","3.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.96;102% of Medicaid interim rate","2.51","75","","","Percent of Total Billed Charges","neg_dollar:$2.51","2.88","86","","","Percent of Total Billed Charges","neg_dollar:$2.88","2.34","70","","","Percent of Total Billed Charges","neg_dollar:$2.34","1.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.90;103.5% of Medicaid interim rate","3.35","150","","","Percent of Total Billed Charges","neg_dollar:$5.17;150% of Medicaid interim rate","2.68","80","","","Percent of Total Billed Charges","neg_dollar:$2.68;Percent of Total Billed Charges","3.08","92","","","Percent of Total Billed Charges","neg_dollar:$3.08","1.74","52","","","Percent of Total Billed Charges","neg_dollar:$1.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.35","Fee Schedule","","1.00","3.00",""
"CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN","A9270","HCPCS","60505-0823-6","NDC","250","RC","","Facility","Outpatient","1","UN","92.90","92.90","","","","92.90","Fee Schedule","","","","","92.90","Fee Schedule","","","","","92.90","Fee Schedule","","","52","","92.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","48.30","52","","","Percent of Total Billed Charges","neg_dollar:$48.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","48.30","52","","","Percent of Total Billed Charges","neg_dollar:$48.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","79.89","86","","","Percent of Total Billed Charges","neg_dollar:$79.89","65.03","70","","","Percent of Total Billed Charges","neg_dollar:$65.03","","52","","92.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","54.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.57;102% of Medicaid interim rate","69.67","75","","","Percent of Total Billed Charges","neg_dollar:$69.67","79.89","86","","","Percent of Total Billed Charges","neg_dollar:$79.89","65.03","70","","","Percent of Total Billed Charges","neg_dollar:$65.03","52.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.95;103.5% of Medicaid interim rate","92.90","150","","","Percent of Total Billed Charges","neg_dollar:$143.62;150% of Medicaid interim rate","74.32","80","","","Percent of Total Billed Charges","neg_dollar:$74.32;Percent of Total Billed Charges","85.46","92","","","Percent of Total Billed Charges","neg_dollar:$85.46","48.30","52","","","Percent of Total Billed Charges","neg_dollar:$48.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","92.90","Fee Schedule","","48.00","92.00",""
"AMIODARONE HCL 200 MG PO TABS","A9270","HCPCS","60687-437-11","NDC","250","RC","","Facility","Outpatient","200","ME","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","","52","","1.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.45","Fee Schedule","","1.00","1.00",""
"IBUPROFEN 200 MG PO TABS","A9270","HCPCS","00904-7914-61","NDC","637","RC","","Facility","Outpatient","200","ME","0.80","0.80","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","101% of Medicare Fee Schedule","","","","0.80","Fee Schedule","","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","86","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","70","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% of Medicaid interim rate","0.60","75","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.69","86","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","70","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;103.5% of Medicaid interim rate","0.80","150","","","Percent of Total Billed Charges","neg_dollar:$1.24;150% of Medicaid interim rate","0.64","80","","","Percent of Total Billed Charges","neg_dollar:$0.64;Percent of Total Billed Charges","0.74","92","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"AMIODARONE HCL 200 MG PO TABS","A9270","HCPCS","60687-437-11","NDC","637","RC","","Facility","Outpatient","200","ME","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","101% of Medicare Fee Schedule","","","","1.45","Fee Schedule","","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"AMIODARONE HCL 200 MG PO TABS","A9270","HCPCS","63739-051-10","NDC","637","RC","","Facility","Outpatient","200","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN","A9270","HCPCS","60505-0823-6","NDC","637","RC","","Facility","Outpatient","1","UN","92.90","92.90","","","","92.90","Fee Schedule","","","","","92.90","Fee Schedule","101% of Medicare Fee Schedule","","","","92.90","Fee Schedule","","48.30","52","","","Percent of Total Billed Charges","neg_dollar:$48.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","92.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","92.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","79.89","86","","","Percent of Total Billed Charges","neg_dollar:$79.89","65.03","70","","","Percent of Total Billed Charges","neg_dollar:$65.03","48.30","52","","","Percent of Total Billed Charges","neg_dollar:$48.30;105% Medicare Outpatient Cost to Charge Ratio of 52%","54.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.57;102% of Medicaid interim rate","69.67","75","","","Percent of Total Billed Charges","neg_dollar:$69.67","79.89","86","","","Percent of Total Billed Charges","neg_dollar:$79.89","65.03","70","","","Percent of Total Billed Charges","neg_dollar:$65.03","52.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.95;103.5% of Medicaid interim rate","92.90","150","","","Percent of Total Billed Charges","neg_dollar:$143.62;150% of Medicaid interim rate","74.32","80","","","Percent of Total Billed Charges","neg_dollar:$74.32;Percent of Total Billed Charges","85.46","92","","","Percent of Total Billed Charges","neg_dollar:$85.46","48.30","52","","","Percent of Total Billed Charges","neg_dollar:$48.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.30","52","","","Percent of Total Billed Charges","neg_dollar:$48.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.00","92.00",""
"CARBAMAZEPINE ER 200 MG PO TB12","A9270","HCPCS","60687-583-11","NDC","637","RC","","Facility","Outpatient","200","ME","5.05","5.05","","","","5.05","Fee Schedule","","","","","5.05","Fee Schedule","101% of Medicare Fee Schedule","","","","5.05","Fee Schedule","","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.96;102% of Medicaid interim rate","3.78","75","","","Percent of Total Billed Charges","neg_dollar:$3.78","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.87;103.5% of Medicaid interim rate","5.05","150","","","Percent of Total Billed Charges","neg_dollar:$7.80;150% of Medicaid interim rate","4.04","80","","","Percent of Total Billed Charges","neg_dollar:$4.04;Percent of Total Billed Charges","4.64","92","","","Percent of Total Billed Charges","neg_dollar:$4.64","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"CARBAMAZEPINE 200 MG PO TABS","A9270","HCPCS","00904-6172-61","NDC","637","RC","","Facility","Outpatient","200","ME","2.10","2.10","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","101% of Medicare Fee Schedule","","","","2.10","Fee Schedule","","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% of Medicaid interim rate","1.57","75","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.19;103.5% of Medicaid interim rate","2.10","150","","","Percent of Total Billed Charges","neg_dollar:$3.24;150% of Medicaid interim rate","1.68","80","","","Percent of Total Billed Charges","neg_dollar:$1.68;Percent of Total Billed Charges","1.93","92","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS","A9270","HCPCS","68084-269-11","NDC","637","RC","","Facility","Outpatient","200","ME","3.35","3.35","","","","3.35","Fee Schedule","","","","","3.35","Fee Schedule","101% of Medicare Fee Schedule","","","","3.35","Fee Schedule","","1.74","52","","","Percent of Total Billed Charges","neg_dollar:$1.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","86","","","Percent of Total Billed Charges","neg_dollar:$2.88","2.34","70","","","Percent of Total Billed Charges","neg_dollar:$2.34","1.74","52","","","Percent of Total Billed Charges","neg_dollar:$1.74;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.96;102% of Medicaid interim rate","2.51","75","","","Percent of Total Billed Charges","neg_dollar:$2.51","2.88","86","","","Percent of Total Billed Charges","neg_dollar:$2.88","2.34","70","","","Percent of Total Billed Charges","neg_dollar:$2.34","1.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.90;103.5% of Medicaid interim rate","3.35","150","","","Percent of Total Billed Charges","neg_dollar:$5.17;150% of Medicaid interim rate","2.68","80","","","Percent of Total Billed Charges","neg_dollar:$2.68;Percent of Total Billed Charges","3.08","92","","","Percent of Total Billed Charges","neg_dollar:$3.08","1.74","52","","","Percent of Total Billed Charges","neg_dollar:$1.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.74","52","","","Percent of Total Billed Charges","neg_dollar:$1.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP","A9270","HCPCS","57237-316-03","NDC","250","RC","","Facility","Outpatient","1","UN","3.60","3.60","","","","3.60","Fee Schedule","","","","","3.60","Fee Schedule","","","","","3.60","Fee Schedule","","","52","","3.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.87","52","","","Percent of Total Billed Charges","neg_dollar:$1.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.87","52","","","Percent of Total Billed Charges","neg_dollar:$1.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.09","86","","","Percent of Total Billed Charges","neg_dollar:$3.09","2.52","70","","","Percent of Total Billed Charges","neg_dollar:$2.52","","52","","3.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.11;102% of Medicaid interim rate","2.70","75","","","Percent of Total Billed Charges","neg_dollar:$2.70","3.09","86","","","Percent of Total Billed Charges","neg_dollar:$3.09","2.52","70","","","Percent of Total Billed Charges","neg_dollar:$2.52","2.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.05;103.5% of Medicaid interim rate","3.60","150","","","Percent of Total Billed Charges","neg_dollar:$5.56;150% of Medicaid interim rate","2.88","80","","","Percent of Total Billed Charges","neg_dollar:$2.88;Percent of Total Billed Charges","3.31","92","","","Percent of Total Billed Charges","neg_dollar:$3.31","1.87","52","","","Percent of Total Billed Charges","neg_dollar:$1.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.60","Fee Schedule","","1.00","3.00",""
"ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP","A9270","HCPCS","00121-1761-30","NDC","250","RC","","Facility","Outpatient","1","UN","4.44","4.44","","","","4.44","Fee Schedule","","","","","4.44","Fee Schedule","","","","","4.44","Fee Schedule","","","52","","4.44","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.82","86","","","Percent of Total Billed Charges","neg_dollar:$3.82","3.10","70","","","Percent of Total Billed Charges","neg_dollar:$3.10","","52","","4.44","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.61;102% of Medicaid interim rate","3.33","75","","","Percent of Total Billed Charges","neg_dollar:$3.33","3.82","86","","","Percent of Total Billed Charges","neg_dollar:$3.82","3.10","70","","","Percent of Total Billed Charges","neg_dollar:$3.10","2.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.53;103.5% of Medicaid interim rate","4.44","150","","","Percent of Total Billed Charges","neg_dollar:$6.86;150% of Medicaid interim rate","3.55","80","","","Percent of Total Billed Charges","neg_dollar:$3.55;Percent of Total Billed Charges","4.08","92","","","Percent of Total Billed Charges","neg_dollar:$4.08","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.44","Fee Schedule","","2.00","4.00",""
"ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP","A9270","HCPCS","00121-1761-30","NDC","637","RC","","Facility","Outpatient","1","UN","4.80","4.80","","","","4.80","Fee Schedule","","","","","4.80","Fee Schedule","101% of Medicare Fee Schedule","","","","4.80","Fee Schedule","","2.49","52","","","Percent of Total Billed Charges","neg_dollar:$2.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.12","86","","","Percent of Total Billed Charges","neg_dollar:$4.12","3.36","70","","","Percent of Total Billed Charges","neg_dollar:$3.36","2.49","52","","","Percent of Total Billed Charges","neg_dollar:$2.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.81;102% of Medicaid interim rate","3.59","75","","","Percent of Total Billed Charges","neg_dollar:$3.59","4.12","86","","","Percent of Total Billed Charges","neg_dollar:$4.12","3.36","70","","","Percent of Total Billed Charges","neg_dollar:$3.36","2.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.73;103.5% of Medicaid interim rate","4.80","150","","","Percent of Total Billed Charges","neg_dollar:$7.42;150% of Medicaid interim rate","3.84","80","","","Percent of Total Billed Charges","neg_dollar:$3.84;Percent of Total Billed Charges","4.41","92","","","Percent of Total Billed Charges","neg_dollar:$4.41","2.49","52","","","Percent of Total Billed Charges","neg_dollar:$2.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.49","52","","","Percent of Total Billed Charges","neg_dollar:$2.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP","A9270","HCPCS","57237-316-03","NDC","637","RC","","Facility","Outpatient","1","UN","4.12","4.12","","","","4.12","Fee Schedule","","","","","4.12","Fee Schedule","101% of Medicare Fee Schedule","","","","4.12","Fee Schedule","","2.14","52","","","Percent of Total Billed Charges","neg_dollar:$2.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.54","86","","","Percent of Total Billed Charges","neg_dollar:$3.54","2.88","70","","","Percent of Total Billed Charges","neg_dollar:$2.88","2.14","52","","","Percent of Total Billed Charges","neg_dollar:$2.14;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.42;102% of Medicaid interim rate","3.09","75","","","Percent of Total Billed Charges","neg_dollar:$3.09","3.54","86","","","Percent of Total Billed Charges","neg_dollar:$3.54","2.88","70","","","Percent of Total Billed Charges","neg_dollar:$2.88","2.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.34;103.5% of Medicaid interim rate","4.12","150","","","Percent of Total Billed Charges","neg_dollar:$6.36;150% of Medicaid interim rate","3.29","80","","","Percent of Total Billed Charges","neg_dollar:$3.29;Percent of Total Billed Charges","3.79","92","","","Percent of Total Billed Charges","neg_dollar:$3.79","2.14","52","","","Percent of Total Billed Charges","neg_dollar:$2.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.14","52","","","Percent of Total Billed Charges","neg_dollar:$2.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"NICOTINE 21 MG/24HR TD PT24","A9270","HCPCS","00536-5896-88","NDC","250","RC","","Facility","Outpatient","1","EA","3.10","3.10","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","","","52","","3.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","","52","","3.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% of Medicaid interim rate","2.32","75","","","Percent of Total Billed Charges","neg_dollar:$2.32","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","1.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.76;103.5% of Medicaid interim rate","3.10","150","","","Percent of Total Billed Charges","neg_dollar:$4.79;150% of Medicaid interim rate","2.48","80","","","Percent of Total Billed Charges","neg_dollar:$2.48;Percent of Total Billed Charges","2.85","92","","","Percent of Total Billed Charges","neg_dollar:$2.85","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.10","Fee Schedule","","1.00","3.00",""
"NICOTINE 21 MG/24HR TD PT24","A9270","HCPCS","00536-5896-88","NDC","637","RC","","Facility","Outpatient","1","EA","3.10","3.10","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","101% of Medicare Fee Schedule","","","","3.10","Fee Schedule","","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% of Medicaid interim rate","2.32","75","","","Percent of Total Billed Charges","neg_dollar:$2.32","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","1.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.76;103.5% of Medicaid interim rate","3.10","150","","","Percent of Total Billed Charges","neg_dollar:$4.79;150% of Medicaid interim rate","2.48","80","","","Percent of Total Billed Charges","neg_dollar:$2.48;Percent of Total Billed Charges","2.85","92","","","Percent of Total Billed Charges","neg_dollar:$2.85","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"VERAPAMIL HCL ER 240 MG PO TBCR","A9270","HCPCS","68462-260-01","NDC","637","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"VERAPAMIL HCL ER 240 MG PO TBCR","A9270","HCPCS","68462-260-01","NDC","250","RC","","Facility","Outpatient","1","EA","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"SACUBITRIL-VALSARTAN 24-26 MG PO TABS","A9270","HCPCS","00078-0659-20","NDC","250","RC","","Facility","Outpatient","1","EA","11","11.00","","","","11.00","Fee Schedule","","","","","11.00","Fee Schedule","","","","","11.00","Fee Schedule","","","52","","11.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.46","86","","","Percent of Total Billed Charges","neg_dollar:$9.46","7.70","70","","","Percent of Total Billed Charges","neg_dollar:$7.70","","52","","11.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.46;102% of Medicaid interim rate","8.25","75","","","Percent of Total Billed Charges","neg_dollar:$8.25","9.46","86","","","Percent of Total Billed Charges","neg_dollar:$9.46","7.70","70","","","Percent of Total Billed Charges","neg_dollar:$7.70","6.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.27;103.5% of Medicaid interim rate","11.00","150","","","Percent of Total Billed Charges","neg_dollar:$17.01;150% of Medicaid interim rate","8.80","80","","","Percent of Total Billed Charges","neg_dollar:$8.80;Percent of Total Billed Charges","10.12","92","","","Percent of Total Billed Charges","neg_dollar:$10.12","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","11.00","Fee Schedule","","5.00","11.00",""
"SACUBITRIL-VALSARTAN 24-26 MG PO TABS","A9270","HCPCS","00078-0659-20","NDC","637","RC","","Facility","Outpatient","1","EA","9.43","9.43","","","","9.43","Fee Schedule","","","","","9.43","Fee Schedule","101% of Medicare Fee Schedule","","","","9.43","Fee Schedule","","4.90","52","","","Percent of Total Billed Charges","neg_dollar:$4.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.11","86","","","Percent of Total Billed Charges","neg_dollar:$8.11","6.60","70","","","Percent of Total Billed Charges","neg_dollar:$6.60","4.90","52","","","Percent of Total Billed Charges","neg_dollar:$4.90;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.54;102% of Medicaid interim rate","7.07","75","","","Percent of Total Billed Charges","neg_dollar:$7.07","8.11","86","","","Percent of Total Billed Charges","neg_dollar:$8.11","6.60","70","","","Percent of Total Billed Charges","neg_dollar:$6.60","5.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.37;103.5% of Medicaid interim rate","9.43","150","","","Percent of Total Billed Charges","neg_dollar:$14.59;150% of Medicaid interim rate","7.54","80","","","Percent of Total Billed Charges","neg_dollar:$7.54;Percent of Total Billed Charges","8.68","92","","","Percent of Total Billed Charges","neg_dollar:$8.68","4.90","52","","","Percent of Total Billed Charges","neg_dollar:$4.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.90","52","","","Percent of Total Billed Charges","neg_dollar:$4.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","9.00",""
"METOPROLOL SUCCINATE ER 25 MG PO TB24","A9270","HCPCS","00904-6322-61","NDC","250","RC","","Facility","Outpatient","25","ME","1.80","1.80","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.55","86","","","Percent of Total Billed Charges","neg_dollar:$1.55","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","","52","","1.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;102% of Medicaid interim rate","1.35","75","","","Percent of Total Billed Charges","neg_dollar:$1.35","1.55","86","","","Percent of Total Billed Charges","neg_dollar:$1.55","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;103.5% of Medicaid interim rate","1.80","150","","","Percent of Total Billed Charges","neg_dollar:$2.78;150% of Medicaid interim rate","1.44","80","","","Percent of Total Billed Charges","neg_dollar:$1.44;Percent of Total Billed Charges","1.65","92","","","Percent of Total Billed Charges","neg_dollar:$1.65","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.80","Fee Schedule","","1.00","1.00",""
"CHLORTHALIDONE 25 MG PO TABS","A9270","HCPCS","00904-6900-04","NDC","250","RC","","Facility","Outpatient","25","ME","3.20","3.20","","","","3.20","Fee Schedule","","","","","3.20","Fee Schedule","","","","","3.20","Fee Schedule","","","52","","3.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.66","52","","","Percent of Total Billed Charges","neg_dollar:$1.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.66","52","","","Percent of Total Billed Charges","neg_dollar:$1.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.75","86","","","Percent of Total Billed Charges","neg_dollar:$2.75","2.24","70","","","Percent of Total Billed Charges","neg_dollar:$2.24","","52","","3.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.88;102% of Medicaid interim rate","2.40","75","","","Percent of Total Billed Charges","neg_dollar:$2.40","2.75","86","","","Percent of Total Billed Charges","neg_dollar:$2.75","2.24","70","","","Percent of Total Billed Charges","neg_dollar:$2.24","1.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.82;103.5% of Medicaid interim rate","3.20","150","","","Percent of Total Billed Charges","neg_dollar:$4.94;150% of Medicaid interim rate","2.56","80","","","Percent of Total Billed Charges","neg_dollar:$2.56;Percent of Total Billed Charges","2.94","92","","","Percent of Total Billed Charges","neg_dollar:$2.94","1.66","52","","","Percent of Total Billed Charges","neg_dollar:$1.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.20","Fee Schedule","","1.00","3.00",""
"NORTRIPTYLINE HCL 25 MG PO CAPS","A9270","HCPCS","50268-604-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.22","1.22","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","","","52","","1.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","","52","","1.22","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% of Medicaid interim rate","0.91","75","","","Percent of Total Billed Charges","neg_dollar:$0.91","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;103.5% of Medicaid interim rate","1.22","150","","","Percent of Total Billed Charges","neg_dollar:$1.89;150% of Medicaid interim rate","0.98","80","","","Percent of Total Billed Charges","neg_dollar:$0.98;Percent of Total Billed Charges","1.12","92","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.22","Fee Schedule","","1.00","1.00",""
"HYDROXYZINE HCL 25 MG PO TABS","A9270","HCPCS","63739-486-10","NDC","250","RC","","Facility","Outpatient","25","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"CHOLECALCIFEROL 25 MCG (1000 UT) PO TABS","A9270","HCPCS","20555-03300","NDC","250","RC","","Facility","Outpatient","1","UN","0.52","0.52","","","","0.52","Fee Schedule","","","","","0.52","Fee Schedule","","","","","0.52","Fee Schedule","","","52","","0.52","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","86","","","Percent of Total Billed Charges","neg_dollar:$0.45","0.36","70","","","Percent of Total Billed Charges","neg_dollar:$0.36","","52","","0.52","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.30;102% of Medicaid interim rate","0.39","75","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.45","86","","","Percent of Total Billed Charges","neg_dollar:$0.45","0.36","70","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.30;103.5% of Medicaid interim rate","0.52","150","","","Percent of Total Billed Charges","neg_dollar:$0.81;150% of Medicaid interim rate","0.42","80","","","Percent of Total Billed Charges","neg_dollar:$0.42;Percent of Total Billed Charges","0.48","92","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.52","Fee Schedule","","1.00","1.00",""
"PSYLLIUM 25 % PO PACK","A9270","HCPCS","37000-74087","NDC","250","RC","","Facility","Outpatient","1","UN","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.55","Fee Schedule","","1.00","1.00",""
"HYDROXYZINE PAMOATE 25 MG PO CAPS","A9270","HCPCS","50268-398-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.02","1.02","","","","1.02","Fee Schedule","","","","","1.02","Fee Schedule","","","","","1.02","Fee Schedule","","","52","","1.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","86","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.71","70","","","Percent of Total Billed Charges","neg_dollar:$0.71","","52","","1.02","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% of Medicaid interim rate","0.76","75","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.88","86","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.71","70","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;103.5% of Medicaid interim rate","1.02","150","","","Percent of Total Billed Charges","neg_dollar:$1.58;150% of Medicaid interim rate","0.82","80","","","Percent of Total Billed Charges","neg_dollar:$0.82;Percent of Total Billed Charges","0.94","92","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.02","Fee Schedule","","1.00","1.00",""
"AMITRIPTYLINE HCL 25 MG PO TABS","A9270","HCPCS","60687-433-11","NDC","250","RC","","Facility","Outpatient","25","ME","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","","52","","0.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% of Medicaid interim rate","0.63","75","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.31;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.85","Fee Schedule","","1.00","1.00",""
"HYDROXYZINE HCL 25 MG PO TABS","A9270","HCPCS","60687-675-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"HYDRALAZINE HCL 25 MG PO TABS","A9270","HCPCS","60687-822-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"CHLORTHALIDONE 25 MG PO TABS","A9270","HCPCS","60687-317-95","NDC","250","RC","","Facility","Outpatient","25","ME","3.30","3.30","","","","3.30","Fee Schedule","","","","","3.30","Fee Schedule","","","","","3.30","Fee Schedule","","","52","","3.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.71","52","","","Percent of Total Billed Charges","neg_dollar:$1.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.71","52","","","Percent of Total Billed Charges","neg_dollar:$1.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.83","86","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.30","70","","","Percent of Total Billed Charges","neg_dollar:$2.30","","52","","3.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.93;102% of Medicaid interim rate","2.47","75","","","Percent of Total Billed Charges","neg_dollar:$2.47","2.83","86","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.30","70","","","Percent of Total Billed Charges","neg_dollar:$2.30","1.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.88;103.5% of Medicaid interim rate","3.30","150","","","Percent of Total Billed Charges","neg_dollar:$5.10;150% of Medicaid interim rate","2.64","80","","","Percent of Total Billed Charges","neg_dollar:$2.64;Percent of Total Billed Charges","3.03","92","","","Percent of Total Billed Charges","neg_dollar:$3.03","1.71","52","","","Percent of Total Billed Charges","neg_dollar:$1.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.30","Fee Schedule","","1.00","3.00",""
"SPIRONOLACTONE 25 MG PO TABS","A9270","HCPCS","60687-465-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.13","1.13","","","","1.13","Fee Schedule","","","","","1.13","Fee Schedule","","","","","1.13","Fee Schedule","","","52","","1.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.97","86","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","70","","","Percent of Total Billed Charges","neg_dollar:$0.79","","52","","1.13","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.66;102% of Medicaid interim rate","0.85","75","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.97","86","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","70","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;103.5% of Medicaid interim rate","1.13","150","","","Percent of Total Billed Charges","neg_dollar:$1.75;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.04","92","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.13","Fee Schedule","","1.00","1.00",""
"QUETIAPINE FUMARATE 25 MG PO TABS","A9270","HCPCS","00904-6638-61","NDC","637","RC","","Facility","Outpatient","25","ME","1.18","1.18","","","","1.18","Fee Schedule","","","","","1.18","Fee Schedule","101% of Medicare Fee Schedule","","","","1.18","Fee Schedule","","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","86","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","70","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% of Medicaid interim rate","0.88","75","","","Percent of Total Billed Charges","neg_dollar:$0.88","1.01","86","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","70","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;103.5% of Medicaid interim rate","1.18","150","","","Percent of Total Billed Charges","neg_dollar:$1.82;150% of Medicaid interim rate","0.94","80","","","Percent of Total Billed Charges","neg_dollar:$0.94;Percent of Total Billed Charges","1.08","92","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DIPHENHYDRAMINE HCL 25 MG PO CAPS","A9270","HCPCS","00904-7237-61","NDC","637","RC","","Facility","Outpatient","25","ME","1","1.00","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% of Medicaid interim rate","0.75","75","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.00","150","","","Percent of Total Billed Charges","neg_dollar:$1.54;150% of Medicaid interim rate","0.80","80","","","Percent of Total Billed Charges","neg_dollar:$0.80;Percent of Total Billed Charges","0.92","92","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METOPROLOL SUCCINATE ER 25 MG PO TB24","A9270","HCPCS","00904-6322-61","NDC","637","RC","","Facility","Outpatient","25","ME","1.73","1.73","","","","1.73","Fee Schedule","","","","","1.73","Fee Schedule","101% of Medicare Fee Schedule","","","","1.73","Fee Schedule","","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.73","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.73","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.48","86","","","Percent of Total Billed Charges","neg_dollar:$1.48","1.21","70","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.01;102% of Medicaid interim rate","1.29","75","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.48","86","","","Percent of Total Billed Charges","neg_dollar:$1.48","1.21","70","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.98;103.5% of Medicaid interim rate","1.73","150","","","Percent of Total Billed Charges","neg_dollar:$2.67;150% of Medicaid interim rate","1.38","80","","","Percent of Total Billed Charges","neg_dollar:$1.38;Percent of Total Billed Charges","1.59","92","","","Percent of Total Billed Charges","neg_dollar:$1.59","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CARVEDILOL 25 MG PO TABS","A9270","HCPCS","00904-6303-61","NDC","250","RC","","Facility","Outpatient","25","ME","0.72","0.72","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","52","","0.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","","52","","0.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% of Medicaid interim rate","0.54","75","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.41;103.5% of Medicaid interim rate","0.72","150","","","Percent of Total Billed Charges","neg_dollar:$1.12;150% of Medicaid interim rate","0.58","80","","","Percent of Total Billed Charges","neg_dollar:$0.58;Percent of Total Billed Charges","0.66","92","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.72","Fee Schedule","","1.00","1.00",""
"DIPHENHYDRAMINE HCL 25 MG PO CAPS","A9270","HCPCS","00904-7237-61","NDC","250","RC","","Facility","Outpatient","25","ME","0.78","0.78","","","","0.78","Fee Schedule","","","","","0.78","Fee Schedule","","","","","0.78","Fee Schedule","","","52","","0.78","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","86","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","","52","","0.78","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.58","75","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.67","86","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.78","150","","","Percent of Total Billed Charges","neg_dollar:$1.21;150% of Medicaid interim rate","0.62","80","","","Percent of Total Billed Charges","neg_dollar:$0.62;Percent of Total Billed Charges","0.72","92","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.78","Fee Schedule","","1.00","1.00",""
"HYDROCHLOROTHIAZIDE 25 MG PO TABS","A9270","HCPCS","60687-593-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"QUETIAPINE FUMARATE 25 MG PO TABS","A9270","HCPCS","00904-6638-61","NDC","250","RC","","Facility","Outpatient","25","ME","1.04","1.04","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","52","","1.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.04","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.83","80","","","Percent of Total Billed Charges","neg_dollar:$0.83;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.04","Fee Schedule","","1.00","1.00",""
"METOPROLOL TARTRATE 25 MG PO TABS","A9270","HCPCS","51079-255-01","NDC","250","RC","","Facility","Outpatient","25","ME","0.94","0.94","","","","0.94","Fee Schedule","","","","","0.94","Fee Schedule","","","","","0.94","Fee Schedule","","","52","","0.94","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","","52","","0.94","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.70","75","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;103.5% of Medicaid interim rate","0.94","150","","","Percent of Total Billed Charges","neg_dollar:$1.46;150% of Medicaid interim rate","0.75","80","","","Percent of Total Billed Charges","neg_dollar:$0.75;Percent of Total Billed Charges","0.86","92","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.94","Fee Schedule","","1.00","1.00",""
"HYDROCHLOROTHIAZIDE 25 MG PO TABS","A9270","HCPCS","60687-593-01","NDC","250","RC","","Facility","Outpatient","25","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"CARVEDILOL 25 MG PO TABS","A9270","HCPCS","68001-152-00","NDC","250","RC","","Facility","Outpatient","25","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"HYDROXYZINE PAMOATE 25 MG PO CAPS","A9270","HCPCS","50268-398-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","101% of Medicare Fee Schedule","","","","1.55","Fee Schedule","","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FENTANYL 25 MCG/HR TD PT72","A9270","HCPCS","47781-424-11","NDC","637","RC","","Facility","Outpatient","1","UN","9.60","9.60","","","","9.60","Fee Schedule","","","","","9.60","Fee Schedule","101% of Medicare Fee Schedule","","","","9.60","Fee Schedule","","4.99","52","","","Percent of Total Billed Charges","neg_dollar:$4.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.25","86","","","Percent of Total Billed Charges","neg_dollar:$8.25","6.72","70","","","Percent of Total Billed Charges","neg_dollar:$6.72","4.99","52","","","Percent of Total Billed Charges","neg_dollar:$4.99;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.63;102% of Medicaid interim rate","7.19","75","","","Percent of Total Billed Charges","neg_dollar:$7.19","8.25","86","","","Percent of Total Billed Charges","neg_dollar:$8.25","6.72","70","","","Percent of Total Billed Charges","neg_dollar:$6.72","5.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.47;103.5% of Medicaid interim rate","9.60","150","","","Percent of Total Billed Charges","neg_dollar:$14.84;150% of Medicaid interim rate","7.68","80","","","Percent of Total Billed Charges","neg_dollar:$7.68;Percent of Total Billed Charges","8.83","92","","","Percent of Total Billed Charges","neg_dollar:$8.83","4.99","52","","","Percent of Total Billed Charges","neg_dollar:$4.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.99","52","","","Percent of Total Billed Charges","neg_dollar:$4.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","9.00",""
"METOPROLOL TARTRATE 25 MG PO TABS","A9270","HCPCS","51079-255-20","NDC","637","RC","","Facility","Outpatient","25","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","101% of Medicare Fee Schedule","","","","1.15","Fee Schedule","","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SPIRONOLACTONE 25 MG PO TABS","A9270","HCPCS","60687-465-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","101% of Medicare Fee Schedule","","","","1.15","Fee Schedule","","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"NORTRIPTYLINE HCL 25 MG PO CAPS","A9270","HCPCS","50268-604-11","NDC","637","RC","","Facility","Outpatient","25","ME","0.94","0.94","","","","0.94","Fee Schedule","","","","","0.94","Fee Schedule","101% of Medicare Fee Schedule","","","","0.94","Fee Schedule","","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.94","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.94","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.70","75","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;103.5% of Medicaid interim rate","0.94","150","","","Percent of Total Billed Charges","neg_dollar:$1.45;150% of Medicaid interim rate","0.75","80","","","Percent of Total Billed Charges","neg_dollar:$0.75;Percent of Total Billed Charges","0.86","92","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HYDROXYZINE HCL 25 MG PO TABS","A9270","HCPCS","63739-486-10","NDC","637","RC","","Facility","Outpatient","25","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","101% of Medicare Fee Schedule","","","","1.35","Fee Schedule","","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CHOLECALCIFEROL 25 MCG (1000 UT) PO TABS","A9270","HCPCS","20555-03300","NDC","637","RC","","Facility","Outpatient","1","UN","0.61","0.61","","","","0.61","Fee Schedule","","","","","0.61","Fee Schedule","101% of Medicare Fee Schedule","","","","0.61","Fee Schedule","","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","86","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.43","70","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.36;102% of Medicaid interim rate","0.46","75","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.52","86","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.43","70","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.35;103.5% of Medicaid interim rate","0.61","150","","","Percent of Total Billed Charges","neg_dollar:$0.95;150% of Medicaid interim rate","0.49","80","","","Percent of Total Billed Charges","neg_dollar:$0.49;Percent of Total Billed Charges","0.56","92","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PSYLLIUM 25 % PO PACK","A9270","HCPCS","37000-74087","NDC","637","RC","","Facility","Outpatient","1","UN","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","101% of Medicare Fee Schedule","","","","1.55","Fee Schedule","","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"AMITRIPTYLINE HCL 25 MG PO TABS","A9270","HCPCS","60687-433-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.28","1.28","","","","1.28","Fee Schedule","","","","","1.28","Fee Schedule","101% of Medicare Fee Schedule","","","","1.28","Fee Schedule","","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.10","86","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% of Medicaid interim rate","0.96","75","","","Percent of Total Billed Charges","neg_dollar:$0.96","1.10","86","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;103.5% of Medicaid interim rate","1.28","150","","","Percent of Total Billed Charges","neg_dollar:$1.99;150% of Medicaid interim rate","1.03","80","","","Percent of Total Billed Charges","neg_dollar:$1.03;Percent of Total Billed Charges","1.18","92","","","Percent of Total Billed Charges","neg_dollar:$1.18","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HYDROXYZINE HCL 25 MG PO TABS","A9270","HCPCS","60687-675-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","101% of Medicare Fee Schedule","","","","1.40","Fee Schedule","","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HYDRALAZINE HCL 25 MG PO TABS","A9270","HCPCS","60687-822-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"INDOMETHACIN 25 MG PO CAPS","A9270","HCPCS","50268-430-11","NDC","637","RC","","Facility","Outpatient","25","ME","0.95","0.95","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","101% of Medicare Fee Schedule","","","","0.95","Fee Schedule","","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.71","75","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;103.5% of Medicaid interim rate","0.95","150","","","Percent of Total Billed Charges","neg_dollar:$1.46;150% of Medicaid interim rate","0.76","80","","","Percent of Total Billed Charges","neg_dollar:$0.76;Percent of Total Billed Charges","0.87","92","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HYDROCHLOROTHIAZIDE 25 MG PO TABS","A9270","HCPCS","60687-593-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CARVEDILOL 25 MG PO TABS","A9270","HCPCS","68001-152-00","NDC","637","RC","","Facility","Outpatient","25","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PREGABALIN 25 MG PO CAPS","A9270","HCPCS","55700-827-90","NDC","637","RC","","Facility","Outpatient","25","ME","10.40","10.40","","","","10.40","Fee Schedule","","","","","10.40","Fee Schedule","101% of Medicare Fee Schedule","","","","10.40","Fee Schedule","","5.40","52","","","Percent of Total Billed Charges","neg_dollar:$5.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.94","86","","","Percent of Total Billed Charges","neg_dollar:$8.94","7.27","70","","","Percent of Total Billed Charges","neg_dollar:$7.27","5.40","52","","","Percent of Total Billed Charges","neg_dollar:$5.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.10;102% of Medicaid interim rate","7.80","75","","","Percent of Total Billed Charges","neg_dollar:$7.80","8.94","86","","","Percent of Total Billed Charges","neg_dollar:$8.94","7.27","70","","","Percent of Total Billed Charges","neg_dollar:$7.27","5.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.92;103.5% of Medicaid interim rate","10.40","150","","","Percent of Total Billed Charges","neg_dollar:$16.07;150% of Medicaid interim rate","8.32","80","","","Percent of Total Billed Charges","neg_dollar:$8.32;Percent of Total Billed Charges","9.56","92","","","Percent of Total Billed Charges","neg_dollar:$9.56","5.40","52","","","Percent of Total Billed Charges","neg_dollar:$5.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.40","52","","","Percent of Total Billed Charges","neg_dollar:$5.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"CARVEDILOL 25 MG PO TABS","A9270","HCPCS","00904-6303-61","NDC","637","RC","","Facility","Outpatient","25","ME","0.95","0.95","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","101% of Medicare Fee Schedule","","","","0.95","Fee Schedule","","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","86","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% of Medicaid interim rate","0.71","75","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.82","86","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;103.5% of Medicaid interim rate","0.95","150","","","Percent of Total Billed Charges","neg_dollar:$1.47;150% of Medicaid interim rate","0.76","80","","","Percent of Total Billed Charges","neg_dollar:$0.76;Percent of Total Billed Charges","0.88","92","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METOPROLOL TARTRATE 25 MG PO TABS","A9270","HCPCS","51079-255-01","NDC","637","RC","","Facility","Outpatient","25","ME","0.81","0.81","","","","0.81","Fee Schedule","","","","","0.81","Fee Schedule","101% of Medicare Fee Schedule","","","","0.81","Fee Schedule","","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","86","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","70","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% of Medicaid interim rate","0.61","75","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.69","86","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","70","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;103.5% of Medicaid interim rate","0.81","150","","","Percent of Total Billed Charges","neg_dollar:$1.25;150% of Medicaid interim rate","0.65","80","","","Percent of Total Billed Charges","neg_dollar:$0.65;Percent of Total Billed Charges","0.74","92","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MECLIZINE HCL 25 MG PO TABS","A9270","HCPCS","60687-730-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.66","1.66","","","","1.66","Fee Schedule","","","","","1.66","Fee Schedule","101% of Medicare Fee Schedule","","","","1.66","Fee Schedule","","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.42","86","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.16","70","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.97;102% of Medicaid interim rate","1.24","75","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.42","86","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.16","70","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.66","150","","","Percent of Total Billed Charges","neg_dollar:$2.57;150% of Medicaid interim rate","1.33","80","","","Percent of Total Billed Charges","neg_dollar:$1.33;Percent of Total Billed Charges","1.52","92","","","Percent of Total Billed Charges","neg_dollar:$1.52","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"AZITHROMYCIN 250 MG PO TABS","A9270","HCPCS","00904-7350-06","NDC","250","RC","","Facility","Outpatient","250","ME","3.86","3.86","","","","3.86","Fee Schedule","","","","","3.86","Fee Schedule","","","","","3.86","Fee Schedule","","","52","","3.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.01","52","","","Percent of Total Billed Charges","neg_dollar:$2.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.01","52","","","Percent of Total Billed Charges","neg_dollar:$2.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.32","86","","","Percent of Total Billed Charges","neg_dollar:$3.32","2.70","70","","","Percent of Total Billed Charges","neg_dollar:$2.70","","52","","3.86","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.27;102% of Medicaid interim rate","2.90","75","","","Percent of Total Billed Charges","neg_dollar:$2.90","3.32","86","","","Percent of Total Billed Charges","neg_dollar:$3.32","2.70","70","","","Percent of Total Billed Charges","neg_dollar:$2.70","2.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.20;103.5% of Medicaid interim rate","3.86","150","","","Percent of Total Billed Charges","neg_dollar:$5.98;150% of Medicaid interim rate","3.09","80","","","Percent of Total Billed Charges","neg_dollar:$3.09;Percent of Total Billed Charges","3.55","92","","","Percent of Total Billed Charges","neg_dollar:$3.55","2.01","52","","","Percent of Total Billed Charges","neg_dollar:$2.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.86","Fee Schedule","","2.00","3.00",""
"AZITHROMYCIN 250 MG PO TABS","A9270","HCPCS","60687-742-01","NDC","250","RC","","Facility","Outpatient","250","ME","5.20","5.20","","","","5.20","Fee Schedule","","","","","5.20","Fee Schedule","","","","","5.20","Fee Schedule","","","52","","5.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.47","86","","","Percent of Total Billed Charges","neg_dollar:$4.47","3.63","70","","","Percent of Total Billed Charges","neg_dollar:$3.63","","52","","5.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.05;102% of Medicaid interim rate","3.90","75","","","Percent of Total Billed Charges","neg_dollar:$3.90","4.47","86","","","Percent of Total Billed Charges","neg_dollar:$4.47","3.63","70","","","Percent of Total Billed Charges","neg_dollar:$3.63","2.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.96;103.5% of Medicaid interim rate","5.20","150","","","Percent of Total Billed Charges","neg_dollar:$8.03;150% of Medicaid interim rate","4.16","80","","","Percent of Total Billed Charges","neg_dollar:$4.16;Percent of Total Billed Charges","4.78","92","","","Percent of Total Billed Charges","neg_dollar:$4.78","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.20","Fee Schedule","","2.00","5.00",""
"AZITHROMYCIN 250 MG PO TABS","A9270","HCPCS","60687-742-65","NDC","250","RC","","Facility","Outpatient","250","ME","3.82","3.82","","","","3.82","Fee Schedule","","","","","3.82","Fee Schedule","","","","","3.82","Fee Schedule","","","52","","3.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.28","86","","","Percent of Total Billed Charges","neg_dollar:$3.28","2.67","70","","","Percent of Total Billed Charges","neg_dollar:$2.67","","52","","3.82","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.24;102% of Medicaid interim rate","2.86","75","","","Percent of Total Billed Charges","neg_dollar:$2.86","3.28","86","","","Percent of Total Billed Charges","neg_dollar:$3.28","2.67","70","","","Percent of Total Billed Charges","neg_dollar:$2.67","2.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.18;103.5% of Medicaid interim rate","3.82","150","","","Percent of Total Billed Charges","neg_dollar:$5.91;150% of Medicaid interim rate","3.06","80","","","Percent of Total Billed Charges","neg_dollar:$3.06;Percent of Total Billed Charges","3.51","92","","","Percent of Total Billed Charges","neg_dollar:$3.51","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.82","Fee Schedule","","1.00","3.00",""
"CEFUROXIME AXETIL 250 MG PO TABS","A9270","HCPCS","60687-272-11","NDC","250","RC","","Facility","Outpatient","250","ME","5.55","5.55","","","","5.55","Fee Schedule","","","","","5.55","Fee Schedule","","","","","5.55","Fee Schedule","","","52","","5.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.77","86","","","Percent of Total Billed Charges","neg_dollar:$4.77","3.88","70","","","Percent of Total Billed Charges","neg_dollar:$3.88","","52","","5.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.26;102% of Medicaid interim rate","4.16","75","","","Percent of Total Billed Charges","neg_dollar:$4.16","4.77","86","","","Percent of Total Billed Charges","neg_dollar:$4.77","3.88","70","","","Percent of Total Billed Charges","neg_dollar:$3.88","3.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.16;103.5% of Medicaid interim rate","5.55","150","","","Percent of Total Billed Charges","neg_dollar:$8.58;150% of Medicaid interim rate","4.44","80","","","Percent of Total Billed Charges","neg_dollar:$4.44;Percent of Total Billed Charges","5.10","92","","","Percent of Total Billed Charges","neg_dollar:$5.10","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.55","Fee Schedule","","2.00","5.00",""
"CEFUROXIME AXETIL 250 MG PO TABS","A9270","HCPCS","60687-272-94","NDC","250","RC","","Facility","Outpatient","250","ME","5.55","5.55","","","","5.55","Fee Schedule","","","","","5.55","Fee Schedule","","","","","5.55","Fee Schedule","","","52","","5.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.77","86","","","Percent of Total Billed Charges","neg_dollar:$4.77","3.88","70","","","Percent of Total Billed Charges","neg_dollar:$3.88","","52","","5.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.26;102% of Medicaid interim rate","4.16","75","","","Percent of Total Billed Charges","neg_dollar:$4.16","4.77","86","","","Percent of Total Billed Charges","neg_dollar:$4.77","3.88","70","","","Percent of Total Billed Charges","neg_dollar:$3.88","3.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.16;103.5% of Medicaid interim rate","5.55","150","","","Percent of Total Billed Charges","neg_dollar:$8.58;150% of Medicaid interim rate","4.44","80","","","Percent of Total Billed Charges","neg_dollar:$4.44;Percent of Total Billed Charges","5.10","92","","","Percent of Total Billed Charges","neg_dollar:$5.10","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.55","Fee Schedule","","2.00","5.00",""
"DIVALPROEX SODIUM 250 MG PO TBEC","A9270","HCPCS","00832-7123-89","NDC","250","RC","","Facility","Outpatient","250","ME","0.72","0.72","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","52","","0.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","","52","","0.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% of Medicaid interim rate","0.54","75","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.41;103.5% of Medicaid interim rate","0.72","150","","","Percent of Total Billed Charges","neg_dollar:$1.12;150% of Medicaid interim rate","0.58","80","","","Percent of Total Billed Charges","neg_dollar:$0.58;Percent of Total Billed Charges","0.66","92","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.72","Fee Schedule","","1.00","1.00",""
"AZITHROMYCIN 250 MG PO TABS","A9270","HCPCS","60687-742-01","NDC","637","RC","","Facility","Outpatient","250","ME","5.20","5.20","","","","5.20","Fee Schedule","","","","","5.20","Fee Schedule","101% of Medicare Fee Schedule","","","","5.20","Fee Schedule","","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.47","86","","","Percent of Total Billed Charges","neg_dollar:$4.47","3.63","70","","","Percent of Total Billed Charges","neg_dollar:$3.63","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","3.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.05;102% of Medicaid interim rate","3.90","75","","","Percent of Total Billed Charges","neg_dollar:$3.90","4.47","86","","","Percent of Total Billed Charges","neg_dollar:$4.47","3.63","70","","","Percent of Total Billed Charges","neg_dollar:$3.63","2.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.96;103.5% of Medicaid interim rate","5.20","150","","","Percent of Total Billed Charges","neg_dollar:$8.03;150% of Medicaid interim rate","4.16","80","","","Percent of Total Billed Charges","neg_dollar:$4.16;Percent of Total Billed Charges","4.78","92","","","Percent of Total Billed Charges","neg_dollar:$4.78","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"AZITHROMYCIN 250 MG PO TABS","A9270","HCPCS","60687-742-65","NDC","637","RC","","Facility","Outpatient","250","ME","4.75","4.75","","","","4.75","Fee Schedule","","","","","4.75","Fee Schedule","101% of Medicare Fee Schedule","","","","4.75","Fee Schedule","","2.47","52","","","Percent of Total Billed Charges","neg_dollar:$2.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.08","86","","","Percent of Total Billed Charges","neg_dollar:$4.08","3.32","70","","","Percent of Total Billed Charges","neg_dollar:$3.32","2.47","52","","","Percent of Total Billed Charges","neg_dollar:$2.47;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.79;102% of Medicaid interim rate","3.56","75","","","Percent of Total Billed Charges","neg_dollar:$3.56","4.08","86","","","Percent of Total Billed Charges","neg_dollar:$4.08","3.32","70","","","Percent of Total Billed Charges","neg_dollar:$3.32","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;103.5% of Medicaid interim rate","4.75","150","","","Percent of Total Billed Charges","neg_dollar:$7.34;150% of Medicaid interim rate","3.80","80","","","Percent of Total Billed Charges","neg_dollar:$3.80;Percent of Total Billed Charges","4.37","92","","","Percent of Total Billed Charges","neg_dollar:$4.37","2.47","52","","","Percent of Total Billed Charges","neg_dollar:$2.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.47","52","","","Percent of Total Billed Charges","neg_dollar:$2.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"AZITHROMYCIN 250 MG PO TABS","A9270","HCPCS","00904-7350-06","NDC","637","RC","","Facility","Outpatient","250","ME","4","4.00","","","","4.00","Fee Schedule","","","","","4.00","Fee Schedule","101% of Medicare Fee Schedule","","","","4.00","Fee Schedule","","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.44","86","","","Percent of Total Billed Charges","neg_dollar:$3.44","2.80","70","","","Percent of Total Billed Charges","neg_dollar:$2.80","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.34;102% of Medicaid interim rate","3.00","75","","","Percent of Total Billed Charges","neg_dollar:$3","3.44","86","","","Percent of Total Billed Charges","neg_dollar:$3.44","2.80","70","","","Percent of Total Billed Charges","neg_dollar:$2.80","2.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.28;103.5% of Medicaid interim rate","4.00","150","","","Percent of Total Billed Charges","neg_dollar:$6.18;150% of Medicaid interim rate","3.20","80","","","Percent of Total Billed Charges","neg_dollar:$3.20;Percent of Total Billed Charges","3.68","92","","","Percent of Total Billed Charges","neg_dollar:$3.68","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"DIVALPROEX SODIUM 250 MG PO TBEC","A9270","HCPCS","68084-776-11","NDC","637","RC","","Facility","Outpatient","250","ME","0.82","0.82","","","","0.82","Fee Schedule","","","","","0.82","Fee Schedule","101% of Medicare Fee Schedule","","","","0.82","Fee Schedule","","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","86","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% of Medicaid interim rate","0.61","75","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.71","86","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;103.5% of Medicaid interim rate","0.82","150","","","Percent of Total Billed Charges","neg_dollar:$1.27;150% of Medicaid interim rate","0.66","80","","","Percent of Total Billed Charges","neg_dollar:$0.66;Percent of Total Billed Charges","0.76","92","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DIVALPROEX SODIUM 250 MG PO TBEC","A9270","HCPCS","68084-776-11","NDC","250","RC","","Facility","Outpatient","250","ME","0.55","0.55","","","","0.55","Fee Schedule","","","","","0.55","Fee Schedule","","","","","0.55","Fee Schedule","","","52","","0.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","","52","","0.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% of Medicaid interim rate","0.41","75","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.31;103.5% of Medicaid interim rate","0.55","150","","","Percent of Total Billed Charges","neg_dollar:$0.85;150% of Medicaid interim rate","0.44","80","","","Percent of Total Billed Charges","neg_dollar:$0.44;Percent of Total Billed Charges","0.50","92","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.55","Fee Schedule","","1.00","1.00",""
"DIVALPROEX SODIUM 250 MG PO TBEC","A9270","HCPCS","00832-7123-89","NDC","637","RC","","Facility","Outpatient","250","ME","0.77","0.77","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","101% of Medicare Fee Schedule","","","","0.77","Fee Schedule","","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.58","75","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.77","150","","","Percent of Total Billed Charges","neg_dollar:$1.19;150% of Medicaid interim rate","0.62","80","","","Percent of Total Billed Charges","neg_dollar:$0.62;Percent of Total Billed Charges","0.71","92","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CARBIDOPA-LEVODOPA 25-100 MG PO TABS","A9270","HCPCS","60687-661-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","","52","","1.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.45","Fee Schedule","","1.00","1.00",""
"CARBIDOPA-LEVODOPA 25-100 MG PO TABS","A9270","HCPCS","60687-661-01","NDC","250","RC","","Facility","Outpatient","1","EA","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","","52","","1.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.45","Fee Schedule","","1.00","1.00",""
"CARBIDOPA-LEVODOPA 25-100 MG PO TABS","A9270","HCPCS","60687-661-11","NDC","637","RC","","Facility","Outpatient","1","EA","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","101% of Medicare Fee Schedule","","","","1.45","Fee Schedule","","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MELATONIN 3 MG PO TABS","A9270","HCPCS","20555-03601","NDC","250","RC","","Facility","Outpatient","3","ME","0.68","0.68","","","","0.68","Fee Schedule","","","","","0.68","Fee Schedule","","","","","0.68","Fee Schedule","","","52","","0.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","86","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","70","","","Percent of Total Billed Charges","neg_dollar:$0.48","","52","","0.68","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% of Medicaid interim rate","0.51","75","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.59","86","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","70","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.39;103.5% of Medicaid interim rate","0.68","150","","","Percent of Total Billed Charges","neg_dollar:$1.06;150% of Medicaid interim rate","0.55","80","","","Percent of Total Billed Charges","neg_dollar:$0.55;Percent of Total Billed Charges","0.63","92","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.68","Fee Schedule","","1.00","1.00",""
"MELATONIN 3 MG PO TABS","A9270","HCPCS","68094-110-61","NDC","250","RC","","Facility","Outpatient","3","ME","0.77","0.77","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","","52","","0.77","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.58","75","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.77","150","","","Percent of Total Billed Charges","neg_dollar:$1.19;150% of Medicaid interim rate","0.62","80","","","Percent of Total Billed Charges","neg_dollar:$0.62;Percent of Total Billed Charges","0.71","92","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.77","Fee Schedule","","1.00","1.00",""
"MELATONIN 3 MG PO TABS","A9270","HCPCS","20555-03601","NDC","637","RC","","Facility","Outpatient","3","ME","0.58","0.58","","","","0.58","Fee Schedule","","","","","0.58","Fee Schedule","101% of Medicare Fee Schedule","","","","0.58","Fee Schedule","","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","86","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.41","70","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.34;102% of Medicaid interim rate","0.43","75","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.50","86","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.41","70","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.33;103.5% of Medicaid interim rate","0.58","150","","","Percent of Total Billed Charges","neg_dollar:$0.90;150% of Medicaid interim rate","0.46","80","","","Percent of Total Billed Charges","neg_dollar:$0.46;Percent of Total Billed Charges","0.53","92","","","Percent of Total Billed Charges","neg_dollar:$0.53","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MELATONIN 3 MG PO TABS","A9270","HCPCS","68094-110-59","NDC","637","RC","","Facility","Outpatient","3","ME","0.54","0.54","","","","0.54","Fee Schedule","","","","","0.54","Fee Schedule","101% of Medicare Fee Schedule","","","","0.54","Fee Schedule","","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.54","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.54","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","86","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% of Medicaid interim rate","0.40","75","","","Percent of Total Billed Charges","neg_dollar:$0.40","0.46","86","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.31;103.5% of Medicaid interim rate","0.54","150","","","Percent of Total Billed Charges","neg_dollar:$0.84;150% of Medicaid interim rate","0.43","80","","","Percent of Total Billed Charges","neg_dollar:$0.43;Percent of Total Billed Charges","0.50","92","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CARVEDILOL 3.125 MG PO TABS","A9270","HCPCS","00904-6300-61","NDC","250","RC","","Facility","Outpatient","1","EA","0.56","0.56","","","","0.56","Fee Schedule","","","","","0.56","Fee Schedule","","","","","0.56","Fee Schedule","","","52","","0.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","86","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","70","","","Percent of Total Billed Charges","neg_dollar:$0.39","","52","","0.56","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% of Medicaid interim rate","0.42","75","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.48","86","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","70","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;103.5% of Medicaid interim rate","0.56","150","","","Percent of Total Billed Charges","neg_dollar:$0.86;150% of Medicaid interim rate","0.44","80","","","Percent of Total Billed Charges","neg_dollar:$0.44;Percent of Total Billed Charges","0.51","92","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.56","Fee Schedule","","1.00","1.00",""
"CARVEDILOL 3.125 MG PO TABS","A9270","HCPCS","00904-6300-61","NDC","637","RC","","Facility","Outpatient","1","EA","0.37","0.37","","","","0.37","Fee Schedule","","","","","0.37","Fee Schedule","101% of Medicare Fee Schedule","","","","0.37","Fee Schedule","","0.19","52","","","Percent of Total Billed Charges","neg_dollar:$0.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","86","","","Percent of Total Billed Charges","neg_dollar:$0.32","0.26","70","","","Percent of Total Billed Charges","neg_dollar:$0.26","0.19","52","","","Percent of Total Billed Charges","neg_dollar:$0.19;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.22;102% of Medicaid interim rate","0.28","75","","","Percent of Total Billed Charges","neg_dollar:$0.28","0.32","86","","","Percent of Total Billed Charges","neg_dollar:$0.32","0.26","70","","","Percent of Total Billed Charges","neg_dollar:$0.26","0.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.21;103.5% of Medicaid interim rate","0.37","150","","","Percent of Total Billed Charges","neg_dollar:$0.58;150% of Medicaid interim rate","0.30","80","","","Percent of Total Billed Charges","neg_dollar:$0.30;Percent of Total Billed Charges","0.34","92","","","Percent of Total Billed Charges","neg_dollar:$0.34","0.19","52","","","Percent of Total Billed Charges","neg_dollar:$0.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.19","52","","","Percent of Total Billed Charges","neg_dollar:$0.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CARVEDILOL 3.125 MG PO TABS","A9270","HCPCS","00904-7305-61","NDC","250","RC","","Facility","Outpatient","1","EA","0.64","0.64","","","","0.64","Fee Schedule","","","","","0.64","Fee Schedule","","","","","0.64","Fee Schedule","","","52","","0.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","","52","","0.64","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% of Medicaid interim rate","0.48","75","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","0.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.36;103.5% of Medicaid interim rate","0.64","150","","","Percent of Total Billed Charges","neg_dollar:$0.99;150% of Medicaid interim rate","0.51","80","","","Percent of Total Billed Charges","neg_dollar:$0.51;Percent of Total Billed Charges","0.59","92","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.64","Fee Schedule","","1.00","1.00",""
"CARVEDILOL 3.125 MG PO TABS","A9270","HCPCS","68001-153-00","NDC","250","RC","","Facility","Outpatient","1","EA","0.42","0.42","","","","0.42","Fee Schedule","","","","","0.42","Fee Schedule","","","","","0.42","Fee Schedule","","","52","","0.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.22","52","","","Percent of Total Billed Charges","neg_dollar:$0.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.22","52","","","Percent of Total Billed Charges","neg_dollar:$0.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","86","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.29","70","","","Percent of Total Billed Charges","neg_dollar:$0.29","","52","","0.42","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.25;102% of Medicaid interim rate","0.32","75","","","Percent of Total Billed Charges","neg_dollar:$0.32","0.36","86","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.29","70","","","Percent of Total Billed Charges","neg_dollar:$0.29","0.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.24;103.5% of Medicaid interim rate","0.42","150","","","Percent of Total Billed Charges","neg_dollar:$0.66;150% of Medicaid interim rate","0.34","80","","","Percent of Total Billed Charges","neg_dollar:$0.34;Percent of Total Billed Charges","0.39","92","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.22","52","","","Percent of Total Billed Charges","neg_dollar:$0.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.42","Fee Schedule","","1.00","1.00",""
"CARVEDILOL 3.125 MG PO TABS","A9270","HCPCS","68001-153-00","NDC","637","RC","","Facility","Outpatient","1","EA","0.40","0.40","","","","0.40","Fee Schedule","","","","","0.40","Fee Schedule","101% of Medicare Fee Schedule","","","","0.40","Fee Schedule","","0.20","52","","","Percent of Total Billed Charges","neg_dollar:$0.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.34","86","","","Percent of Total Billed Charges","neg_dollar:$0.34","0.27","70","","","Percent of Total Billed Charges","neg_dollar:$0.27","0.20","52","","","Percent of Total Billed Charges","neg_dollar:$0.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.23;102% of Medicaid interim rate","0.30","75","","","Percent of Total Billed Charges","neg_dollar:$0.30","0.34","86","","","Percent of Total Billed Charges","neg_dollar:$0.34","0.27","70","","","Percent of Total Billed Charges","neg_dollar:$0.27","0.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.22;103.5% of Medicaid interim rate","0.40","150","","","Percent of Total Billed Charges","neg_dollar:$0.61;150% of Medicaid interim rate","0.32","80","","","Percent of Total Billed Charges","neg_dollar:$0.32;Percent of Total Billed Charges","0.36","92","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.20","52","","","Percent of Total Billed Charges","neg_dollar:$0.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.20","52","","","Percent of Total Billed Charges","neg_dollar:$0.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CARVEDILOL 3.125 MG PO TABS","A9270","HCPCS","00904-7305-61","NDC","637","RC","","Facility","Outpatient","1","EA","0.36","0.36","","","","0.36","Fee Schedule","","","","","0.36","Fee Schedule","101% of Medicare Fee Schedule","","","","0.36","Fee Schedule","","0.18","52","","","Percent of Total Billed Charges","neg_dollar:$0.18;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.31","86","","","Percent of Total Billed Charges","neg_dollar:$0.31","0.25","70","","","Percent of Total Billed Charges","neg_dollar:$0.25","0.18","52","","","Percent of Total Billed Charges","neg_dollar:$0.18;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.21;102% of Medicaid interim rate","0.27","75","","","Percent of Total Billed Charges","neg_dollar:$0.27","0.31","86","","","Percent of Total Billed Charges","neg_dollar:$0.31","0.25","70","","","Percent of Total Billed Charges","neg_dollar:$0.25","0.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.20;103.5% of Medicaid interim rate","0.36","150","","","Percent of Total Billed Charges","neg_dollar:$0.56;150% of Medicaid interim rate","0.29","80","","","Percent of Total Billed Charges","neg_dollar:$0.29;Percent of Total Billed Charges","0.33","92","","","Percent of Total Billed Charges","neg_dollar:$0.33","0.18","52","","","Percent of Total Billed Charges","neg_dollar:$0.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.18","52","","","Percent of Total Billed Charges","neg_dollar:$0.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT","A9270","HCPCS","61314-631-36","NDC","250","RC","","Facility","Outpatient","1","UN","30.35","30.35","","","","30.35","Fee Schedule","","","","","30.35","Fee Schedule","","","","","30.35","Fee Schedule","","","52","","30.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.78","52","","","Percent of Total Billed Charges","neg_dollar:$15.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.78","52","","","Percent of Total Billed Charges","neg_dollar:$15.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.10","86","","","Percent of Total Billed Charges","neg_dollar:$26.10","21.24","70","","","Percent of Total Billed Charges","neg_dollar:$21.24","","52","","30.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","17.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.83;102% of Medicaid interim rate","22.76","75","","","Percent of Total Billed Charges","neg_dollar:$22.76","26.10","86","","","Percent of Total Billed Charges","neg_dollar:$26.10","21.24","70","","","Percent of Total Billed Charges","neg_dollar:$21.24","17.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.29;103.5% of Medicaid interim rate","30.35","150","","","Percent of Total Billed Charges","neg_dollar:$46.92;150% of Medicaid interim rate","24.28","80","","","Percent of Total Billed Charges","neg_dollar:$24.28;Percent of Total Billed Charges","27.92","92","","","Percent of Total Billed Charges","neg_dollar:$27.92","15.78","52","","","Percent of Total Billed Charges","neg_dollar:$15.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","30.35","Fee Schedule","","15.00","30.00",""
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT","A9270","HCPCS","61314-631-36","NDC","637","RC","","Facility","Outpatient","1","UN","30.35","30.35","","","","30.35","Fee Schedule","","","","","30.35","Fee Schedule","101% of Medicare Fee Schedule","","","","30.35","Fee Schedule","","15.78","52","","","Percent of Total Billed Charges","neg_dollar:$15.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","30.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","30.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","26.10","86","","","Percent of Total Billed Charges","neg_dollar:$26.10","21.24","70","","","Percent of Total Billed Charges","neg_dollar:$21.24","15.78","52","","","Percent of Total Billed Charges","neg_dollar:$15.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","17.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.83;102% of Medicaid interim rate","22.76","75","","","Percent of Total Billed Charges","neg_dollar:$22.76","26.10","86","","","Percent of Total Billed Charges","neg_dollar:$26.10","21.24","70","","","Percent of Total Billed Charges","neg_dollar:$21.24","17.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.29;103.5% of Medicaid interim rate","30.35","150","","","Percent of Total Billed Charges","neg_dollar:$46.92;150% of Medicaid interim rate","24.28","80","","","Percent of Total Billed Charges","neg_dollar:$24.28;Percent of Total Billed Charges","27.92","92","","","Percent of Total Billed Charges","neg_dollar:$27.92","15.78","52","","","Percent of Total Billed Charges","neg_dollar:$15.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.78","52","","","Percent of Total Billed Charges","neg_dollar:$15.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.00","30.00",""
"PIOGLITAZONE HCL 30 MG PO TABS","A9270","HCPCS","16729-021-10","NDC","250","RC","","Facility","Outpatient","30","ME","0.72","0.72","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","52","","0.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","","52","","0.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% of Medicaid interim rate","0.54","75","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.41;103.5% of Medicaid interim rate","0.72","150","","","Percent of Total Billed Charges","neg_dollar:$1.12;150% of Medicaid interim rate","0.58","80","","","Percent of Total Billed Charges","neg_dollar:$0.58;Percent of Total Billed Charges","0.66","92","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.72","Fee Schedule","","1.00","1.00",""
"DILTIAZEM HCL 30 MG PO TABS","A9270","HCPCS","00093-0318-01","NDC","250","RC","","Facility","Outpatient","30","ME","1","1.00","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","","52","","1.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% of Medicaid interim rate","0.75","75","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.00","150","","","Percent of Total Billed Charges","neg_dollar:$1.54;150% of Medicaid interim rate","0.80","80","","","Percent of Total Billed Charges","neg_dollar:$0.80;Percent of Total Billed Charges","0.92","92","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.00","Fee Schedule","","1.00","1.00",""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","A9270","HCPCS","62332-413-10","NDC","250","RC","","Facility","Outpatient","30","ME","9.90","9.90","","","","9.90","Fee Schedule","","","","","9.90","Fee Schedule","","","","","9.90","Fee Schedule","","","52","","9.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.14","52","","","Percent of Total Billed Charges","neg_dollar:$5.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.14","52","","","Percent of Total Billed Charges","neg_dollar:$5.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.51","86","","","Percent of Total Billed Charges","neg_dollar:$8.51","6.93","70","","","Percent of Total Billed Charges","neg_dollar:$6.93","","52","","9.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.81;102% of Medicaid interim rate","7.42","75","","","Percent of Total Billed Charges","neg_dollar:$7.42","8.51","86","","","Percent of Total Billed Charges","neg_dollar:$8.51","6.93","70","","","Percent of Total Billed Charges","neg_dollar:$6.93","5.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.64;103.5% of Medicaid interim rate","9.90","150","","","Percent of Total Billed Charges","neg_dollar:$15.30;150% of Medicaid interim rate","7.92","80","","","Percent of Total Billed Charges","neg_dollar:$7.92;Percent of Total Billed Charges","9.10","92","","","Percent of Total Billed Charges","neg_dollar:$9.10","5.14","52","","","Percent of Total Billed Charges","neg_dollar:$5.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","9.90","Fee Schedule","","5.00","9.00",""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","A9270","HCPCS","69238-1264-1","NDC","250","RC","","Facility","Outpatient","30","ME","10.55","10.55","","","","10.55","Fee Schedule","","","","","10.55","Fee Schedule","","","","","10.55","Fee Schedule","","","52","","10.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.48","52","","","Percent of Total Billed Charges","neg_dollar:$5.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.48","52","","","Percent of Total Billed Charges","neg_dollar:$5.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.07","86","","","Percent of Total Billed Charges","neg_dollar:$9.07","7.38","70","","","Percent of Total Billed Charges","neg_dollar:$7.38","","52","","10.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.19;102% of Medicaid interim rate","7.91","75","","","Percent of Total Billed Charges","neg_dollar:$7.91","9.07","86","","","Percent of Total Billed Charges","neg_dollar:$9.07","7.38","70","","","Percent of Total Billed Charges","neg_dollar:$7.38","6.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.01;103.5% of Medicaid interim rate","10.55","150","","","Percent of Total Billed Charges","neg_dollar:$16.31;150% of Medicaid interim rate","8.44","80","","","Percent of Total Billed Charges","neg_dollar:$8.44;Percent of Total Billed Charges","9.70","92","","","Percent of Total Billed Charges","neg_dollar:$9.70","5.48","52","","","Percent of Total Billed Charges","neg_dollar:$5.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.55","Fee Schedule","","5.00","10.00",""
"ISOSORBIDE MONONITRATE ER 30 MG PO TB24","A9270","HCPCS","00904-6449-61","NDC","637","RC","","Facility","Outpatient","30","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","101% of Medicare Fee Schedule","","","","1.05","Fee Schedule","","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.79","75","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.63;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.97","92","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","A9270","HCPCS","64380-797-01","NDC","250","RC","","Facility","Outpatient","30","ME","2.45","2.45","","","","2.45","Fee Schedule","","","","","2.45","Fee Schedule","","","","","2.45","Fee Schedule","","","52","","2.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.27","52","","","Percent of Total Billed Charges","neg_dollar:$1.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.27","52","","","Percent of Total Billed Charges","neg_dollar:$1.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","86","","","Percent of Total Billed Charges","neg_dollar:$2.10","1.71","70","","","Percent of Total Billed Charges","neg_dollar:$1.71","","52","","2.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.43;102% of Medicaid interim rate","1.83","75","","","Percent of Total Billed Charges","neg_dollar:$1.83","2.10","86","","","Percent of Total Billed Charges","neg_dollar:$2.10","1.71","70","","","Percent of Total Billed Charges","neg_dollar:$1.71","1.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.39;103.5% of Medicaid interim rate","2.45","150","","","Percent of Total Billed Charges","neg_dollar:$3.78;150% of Medicaid interim rate","1.96","80","","","Percent of Total Billed Charges","neg_dollar:$1.96;Percent of Total Billed Charges","2.25","92","","","Percent of Total Billed Charges","neg_dollar:$2.25","1.27","52","","","Percent of Total Billed Charges","neg_dollar:$1.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.45","Fee Schedule","","1.00","2.00",""
"ISOSORBIDE MONONITRATE ER 30 MG PO TB24","A9270","HCPCS","00904-6449-61","NDC","250","RC","","Facility","Outpatient","30","ME","1.27","1.27","","","","1.27","Fee Schedule","","","","","1.27","Fee Schedule","","","","","1.27","Fee Schedule","","","52","","1.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","86","","","Percent of Total Billed Charges","neg_dollar:$1.09","0.89","70","","","Percent of Total Billed Charges","neg_dollar:$0.89","","52","","1.27","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;102% of Medicaid interim rate","0.95","75","","","Percent of Total Billed Charges","neg_dollar:$0.95","1.09","86","","","Percent of Total Billed Charges","neg_dollar:$1.09","0.89","70","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.72;103.5% of Medicaid interim rate","1.27","150","","","Percent of Total Billed Charges","neg_dollar:$1.96;150% of Medicaid interim rate","1.01","80","","","Percent of Total Billed Charges","neg_dollar:$1.01;Percent of Total Billed Charges","1.17","92","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.27","Fee Schedule","","1.00","1.00",""
"DULOXETINE HCL 30 MG PO CPEP","A9270","HCPCS","00904-7044-61","NDC","250","RC","","Facility","Outpatient","30","ME","2.38","2.38","","","","2.38","Fee Schedule","","","","","2.38","Fee Schedule","","","","","2.38","Fee Schedule","","","52","","2.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","52","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","52","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.04","86","","","Percent of Total Billed Charges","neg_dollar:$2.04","1.66","70","","","Percent of Total Billed Charges","neg_dollar:$1.66","","52","","2.38","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.40;102% of Medicaid interim rate","1.78","75","","","Percent of Total Billed Charges","neg_dollar:$1.78","2.04","86","","","Percent of Total Billed Charges","neg_dollar:$2.04","1.66","70","","","Percent of Total Billed Charges","neg_dollar:$1.66","1.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.35;103.5% of Medicaid interim rate","2.38","150","","","Percent of Total Billed Charges","neg_dollar:$3.68;150% of Medicaid interim rate","1.90","80","","","Percent of Total Billed Charges","neg_dollar:$1.90;Percent of Total Billed Charges","2.19","92","","","Percent of Total Billed Charges","neg_dollar:$2.19","1.23","52","","","Percent of Total Billed Charges","neg_dollar:$1.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.38","Fee Schedule","","1.00","2.00",""
"PIOGLITAZONE HCL 30 MG PO TABS","A9270","HCPCS","33342-055-10","NDC","250","RC","","Facility","Outpatient","30","ME","0.72","0.72","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","52","","0.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","","52","","0.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% of Medicaid interim rate","0.54","75","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.41;103.5% of Medicaid interim rate","0.72","150","","","Percent of Total Billed Charges","neg_dollar:$1.12;150% of Medicaid interim rate","0.58","80","","","Percent of Total Billed Charges","neg_dollar:$0.58;Percent of Total Billed Charges","0.66","92","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.72","Fee Schedule","","1.00","1.00",""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","A9270","HCPCS","00527-4591-13","NDC","250","RC","","Facility","Outpatient","30","ME","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","","52","","2.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.05","Fee Schedule","","1.00","2.00",""
"DILTIAZEM HCL 30 MG PO TABS","A9270","HCPCS","00093-0318-01","NDC","637","RC","","Facility","Outpatient","30","ME","1.08","1.08","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","101% of Medicare Fee Schedule","","","","1.08","Fee Schedule","","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.08","150","","","Percent of Total Billed Charges","neg_dollar:$1.68;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.00","92","","","Percent of Total Billed Charges","neg_dollar:$1","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","A9270","HCPCS","62332-413-10","NDC","637","RC","","Facility","Outpatient","30","ME","9.90","9.90","","","","9.90","Fee Schedule","","","","","9.90","Fee Schedule","101% of Medicare Fee Schedule","","","","9.90","Fee Schedule","","5.14","52","","","Percent of Total Billed Charges","neg_dollar:$5.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.51","86","","","Percent of Total Billed Charges","neg_dollar:$8.51","6.93","70","","","Percent of Total Billed Charges","neg_dollar:$6.93","5.14","52","","","Percent of Total Billed Charges","neg_dollar:$5.14;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.81;102% of Medicaid interim rate","7.42","75","","","Percent of Total Billed Charges","neg_dollar:$7.42","8.51","86","","","Percent of Total Billed Charges","neg_dollar:$8.51","6.93","70","","","Percent of Total Billed Charges","neg_dollar:$6.93","5.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.64;103.5% of Medicaid interim rate","9.90","150","","","Percent of Total Billed Charges","neg_dollar:$15.30;150% of Medicaid interim rate","7.92","80","","","Percent of Total Billed Charges","neg_dollar:$7.92;Percent of Total Billed Charges","9.10","92","","","Percent of Total Billed Charges","neg_dollar:$9.10","5.14","52","","","Percent of Total Billed Charges","neg_dollar:$5.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.14","52","","","Percent of Total Billed Charges","neg_dollar:$5.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","9.00",""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","A9270","HCPCS","69238-1264-1","NDC","637","RC","","Facility","Outpatient","30","ME","10.55","10.55","","","","10.55","Fee Schedule","","","","","10.55","Fee Schedule","101% of Medicare Fee Schedule","","","","10.55","Fee Schedule","","5.48","52","","","Percent of Total Billed Charges","neg_dollar:$5.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.07","86","","","Percent of Total Billed Charges","neg_dollar:$9.07","7.38","70","","","Percent of Total Billed Charges","neg_dollar:$7.38","5.48","52","","","Percent of Total Billed Charges","neg_dollar:$5.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.19;102% of Medicaid interim rate","7.91","75","","","Percent of Total Billed Charges","neg_dollar:$7.91","9.07","86","","","Percent of Total Billed Charges","neg_dollar:$9.07","7.38","70","","","Percent of Total Billed Charges","neg_dollar:$7.38","6.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.01;103.5% of Medicaid interim rate","10.55","150","","","Percent of Total Billed Charges","neg_dollar:$16.31;150% of Medicaid interim rate","8.44","80","","","Percent of Total Billed Charges","neg_dollar:$8.44;Percent of Total Billed Charges","9.70","92","","","Percent of Total Billed Charges","neg_dollar:$9.70","5.48","52","","","Percent of Total Billed Charges","neg_dollar:$5.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.48","52","","","Percent of Total Billed Charges","neg_dollar:$5.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","A9270","HCPCS","64380-797-01","NDC","637","RC","","Facility","Outpatient","30","ME","2.45","2.45","","","","2.45","Fee Schedule","","","","","2.45","Fee Schedule","101% of Medicare Fee Schedule","","","","2.45","Fee Schedule","","1.27","52","","","Percent of Total Billed Charges","neg_dollar:$1.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","86","","","Percent of Total Billed Charges","neg_dollar:$2.10","1.71","70","","","Percent of Total Billed Charges","neg_dollar:$1.71","1.27","52","","","Percent of Total Billed Charges","neg_dollar:$1.27;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.43;102% of Medicaid interim rate","1.83","75","","","Percent of Total Billed Charges","neg_dollar:$1.83","2.10","86","","","Percent of Total Billed Charges","neg_dollar:$2.10","1.71","70","","","Percent of Total Billed Charges","neg_dollar:$1.71","1.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.39;103.5% of Medicaid interim rate","2.45","150","","","Percent of Total Billed Charges","neg_dollar:$3.78;150% of Medicaid interim rate","1.96","80","","","Percent of Total Billed Charges","neg_dollar:$1.96;Percent of Total Billed Charges","2.25","92","","","Percent of Total Billed Charges","neg_dollar:$2.25","1.27","52","","","Percent of Total Billed Charges","neg_dollar:$1.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.27","52","","","Percent of Total Billed Charges","neg_dollar:$1.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","A9270","HCPCS","00527-4591-13","NDC","637","RC","","Facility","Outpatient","30","ME","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","101% of Medicare Fee Schedule","","","","2.05","Fee Schedule","","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"DULOXETINE HCL 30 MG PO CPEP","A9270","HCPCS","00904-7044-61","NDC","637","RC","","Facility","Outpatient","30","ME","2.24","2.24","","","","2.24","Fee Schedule","","","","","2.24","Fee Schedule","101% of Medicare Fee Schedule","","","","2.24","Fee Schedule","","1.16","52","","","Percent of Total Billed Charges","neg_dollar:$1.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.24","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.24","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.92","86","","","Percent of Total Billed Charges","neg_dollar:$1.92","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.16","52","","","Percent of Total Billed Charges","neg_dollar:$1.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.31;102% of Medicaid interim rate","1.68","75","","","Percent of Total Billed Charges","neg_dollar:$1.68","1.92","86","","","Percent of Total Billed Charges","neg_dollar:$1.92","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.27;103.5% of Medicaid interim rate","2.24","150","","","Percent of Total Billed Charges","neg_dollar:$3.46;150% of Medicaid interim rate","1.79","80","","","Percent of Total Billed Charges","neg_dollar:$1.79;Percent of Total Billed Charges","2.06","92","","","Percent of Total Billed Charges","neg_dollar:$2.06","1.16","52","","","Percent of Total Billed Charges","neg_dollar:$1.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","52","","","Percent of Total Billed Charges","neg_dollar:$1.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"PIOGLITAZONE HCL 30 MG PO TABS","A9270","HCPCS","33342-055-10","NDC","637","RC","","Facility","Outpatient","30","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"URSODIOL 300 MG PO CAPS","A9270","HCPCS","00023-6145-01","NDC","250","RC","","Facility","Outpatient","300","ME","12.45","12.45","","","","12.45","Fee Schedule","","","","","12.45","Fee Schedule","","","","","12.45","Fee Schedule","","","52","","12.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.47","52","","","Percent of Total Billed Charges","neg_dollar:$6.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.47","52","","","Percent of Total Billed Charges","neg_dollar:$6.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.70","86","","","Percent of Total Billed Charges","neg_dollar:$10.70","8.71","70","","","Percent of Total Billed Charges","neg_dollar:$8.71","","52","","12.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.31;102% of Medicaid interim rate","9.33","75","","","Percent of Total Billed Charges","neg_dollar:$9.33","10.70","86","","","Percent of Total Billed Charges","neg_dollar:$10.70","8.71","70","","","Percent of Total Billed Charges","neg_dollar:$8.71","7.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.09;103.5% of Medicaid interim rate","12.45","150","","","Percent of Total Billed Charges","neg_dollar:$19.24;150% of Medicaid interim rate","9.96","80","","","Percent of Total Billed Charges","neg_dollar:$9.96;Percent of Total Billed Charges","11.45","92","","","Percent of Total Billed Charges","neg_dollar:$11.45","6.47","52","","","Percent of Total Billed Charges","neg_dollar:$6.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.45","Fee Schedule","","6.00","12.00",""
"GABAPENTIN 300 MG PO CAPS","A9270","HCPCS","60687-591-01","NDC","250","RC","","Facility","Outpatient","300","ME","0.93","0.93","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","52","","0.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","","52","","0.93","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.70","75","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;103.5% of Medicaid interim rate","0.93","150","","","Percent of Total Billed Charges","neg_dollar:$1.44;150% of Medicaid interim rate","0.75","80","","","Percent of Total Billed Charges","neg_dollar:$0.75;Percent of Total Billed Charges","0.86","92","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.93","Fee Schedule","","1.00","1.00",""
"GABAPENTIN 300 MG PO CAPS","A9270","HCPCS","60687-591-11","NDC","250","RC","","Facility","Outpatient","300","ME","0.96","0.96","","","","0.96","Fee Schedule","","","","","0.96","Fee Schedule","","","","","0.96","Fee Schedule","","","52","","0.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","86","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.67","70","","","Percent of Total Billed Charges","neg_dollar:$0.67","","52","","0.96","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% of Medicaid interim rate","0.72","75","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.83","86","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.67","70","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;103.5% of Medicaid interim rate","0.96","150","","","Percent of Total Billed Charges","neg_dollar:$1.49;150% of Medicaid interim rate","0.77","80","","","Percent of Total Billed Charges","neg_dollar:$0.77;Percent of Total Billed Charges","0.88","92","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.50","52","","","Percent of Total Billed Charges","neg_dollar:$0.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.96","Fee Schedule","","1.00","1.00",""
"CEFDINIR 300 MG PO CAPS","A9270","HCPCS","60687-699-11","NDC","250","RC","","Facility","Outpatient","300","ME","5.05","5.05","","","","5.05","Fee Schedule","","","","","5.05","Fee Schedule","","","","","5.05","Fee Schedule","","","52","","5.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","","52","","5.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.96;102% of Medicaid interim rate","3.78","75","","","Percent of Total Billed Charges","neg_dollar:$3.78","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.87;103.5% of Medicaid interim rate","5.05","150","","","Percent of Total Billed Charges","neg_dollar:$7.80;150% of Medicaid interim rate","4.04","80","","","Percent of Total Billed Charges","neg_dollar:$4.04;Percent of Total Billed Charges","4.64","92","","","Percent of Total Billed Charges","neg_dollar:$4.64","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.05","Fee Schedule","","2.00","5.00",""
"GABAPENTIN 300 MG PO CAPS","A9270","HCPCS","60687-591-11","NDC","637","RC","","Facility","Outpatient","300","ME","0.88","0.88","","","","0.88","Fee Schedule","","","","","0.88","Fee Schedule","101% of Medicare Fee Schedule","","","","0.88","Fee Schedule","","0.45","52","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","86","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.61","70","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.45","52","","","Percent of Total Billed Charges","neg_dollar:$0.45;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;102% of Medicaid interim rate","0.66","75","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.75","86","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.61","70","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.50;103.5% of Medicaid interim rate","0.88","150","","","Percent of Total Billed Charges","neg_dollar:$1.36;150% of Medicaid interim rate","0.70","80","","","Percent of Total Billed Charges","neg_dollar:$0.70;Percent of Total Billed Charges","0.80","92","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.45","52","","","Percent of Total Billed Charges","neg_dollar:$0.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","52","","","Percent of Total Billed Charges","neg_dollar:$0.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"GABAPENTIN 300 MG PO CAPS","A9270","HCPCS","60687-591-01","NDC","637","RC","","Facility","Outpatient","300","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CEFDINIR 300 MG PO CAPS","A9270","HCPCS","60687-699-11","NDC","637","RC","","Facility","Outpatient","300","ME","5.05","5.05","","","","5.05","Fee Schedule","","","","","5.05","Fee Schedule","101% of Medicare Fee Schedule","","","","5.05","Fee Schedule","","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.96;102% of Medicaid interim rate","3.78","75","","","Percent of Total Billed Charges","neg_dollar:$3.78","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.87;103.5% of Medicaid interim rate","5.05","150","","","Percent of Total Billed Charges","neg_dollar:$7.80;150% of Medicaid interim rate","4.04","80","","","Percent of Total Billed Charges","neg_dollar:$4.04;Percent of Total Billed Charges","4.64","92","","","Percent of Total Billed Charges","neg_dollar:$4.64","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"CEFDINIR 300 MG PO CAPS","A9270","HCPCS","60687-699-21","NDC","637","RC","","Facility","Outpatient","300","ME","5.05","5.05","","","","5.05","Fee Schedule","","","","","5.05","Fee Schedule","101% of Medicare Fee Schedule","","","","5.05","Fee Schedule","","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.96;102% of Medicaid interim rate","3.78","75","","","Percent of Total Billed Charges","neg_dollar:$3.78","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.87;103.5% of Medicaid interim rate","5.05","150","","","Percent of Total Billed Charges","neg_dollar:$7.80;150% of Medicaid interim rate","4.04","80","","","Percent of Total Billed Charges","neg_dollar:$4.04;Percent of Total Billed Charges","4.64","92","","","Percent of Total Billed Charges","neg_dollar:$4.64","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"FERROUS GLUCONATE 324 (38 FE) MG PO TABS","A9270","HCPCS","00574-0508-11","NDC","250","RC","","Facility","Outpatient","324","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","","52","","1.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.15","Fee Schedule","","1.00","1.00",""
"FERROUS GLUCONATE 324 (38 FE) MG PO TABS","A9270","HCPCS","00574-0508-11","NDC","637","RC","","Facility","Outpatient","324","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","101% of Medicare Fee Schedule","","","","1.15","Fee Schedule","","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FERROUS SULFATE 325 (65 FE) MG PO TABS","A9270","HCPCS","00904-7591-61","NDC","250","RC","","Facility","Outpatient","325","ME","1.01","1.01","","","","1.01","Fee Schedule","","","","","1.01","Fee Schedule","","","","","1.01","Fee Schedule","","","52","","1.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","86","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","","52","","1.01","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% of Medicaid interim rate","0.76","75","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.87","86","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.01","150","","","Percent of Total Billed Charges","neg_dollar:$1.56;150% of Medicaid interim rate","0.81","80","","","Percent of Total Billed Charges","neg_dollar:$0.81;Percent of Total Billed Charges","0.93","92","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.01","Fee Schedule","","1.00","1.00",""
"ASPIRIN 325 MG PO TBEC","A9270","HCPCS","00536-1232-01","NDC","250","RC","","Facility","Outpatient","325","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","","52","","0.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.50","Fee Schedule","","1.00","1.00",""
"ASPIRIN 325 MG PO TABS","A9270","HCPCS","00536-1054-29","NDC","250","RC","","Facility","Outpatient","325","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","","52","","0.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.50","Fee Schedule","","1.00","1.00",""
"ACETAMINOPHEN 325 MG PO TABS","A9270","HCPCS","00904-6773-61","NDC","250","RC","","Facility","Outpatient","325","ME","0.25","0.25","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","","52","","0.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% of Medicaid interim rate","0.18","75","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.25","150","","","Percent of Total Billed Charges","neg_dollar:$0.38;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.25","Fee Schedule","","1.00","1.00",""
"ASPIRIN 325 MG PO TBEC","A9270","HCPCS","69618-015-01","NDC","250","RC","","Facility","Outpatient","325","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","","52","","0.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.50","Fee Schedule","","1.00","1.00",""
"ASPIRIN 325 MG PO TABS","A9270","HCPCS","00536-1054-29","NDC","637","RC","","Facility","Outpatient","325","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","101% of Medicare Fee Schedule","","","","0.50","Fee Schedule","","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ASPIRIN 325 MG PO TBEC","A9270","HCPCS","00536-1232-01","NDC","637","RC","","Facility","Outpatient","325","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","101% of Medicare Fee Schedule","","","","0.50","Fee Schedule","","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FERROUS SULFATE 325 (65 FE) MG PO TABS","A9270","HCPCS","00904-7591-61","NDC","637","RC","","Facility","Outpatient","325","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","101% of Medicare Fee Schedule","","","","1.05","Fee Schedule","","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ACETAMINOPHEN 325 MG PO TABS","A9270","HCPCS","00904-6773-61","NDC","637","RC","","Facility","Outpatient","325","ME","0.25","0.25","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","101% of Medicare Fee Schedule","","","","0.25","Fee Schedule","","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% of Medicaid interim rate","0.18","75","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.25","150","","","Percent of Total Billed Charges","neg_dollar:$0.38;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TRIAMTERENE-HCTZ 37.5-25 MG PO TABS","A9270","HCPCS","68084-750-25","NDC","637","RC","","Facility","Outpatient","25","ME","2","2.00","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"ONDANSETRON 4 MG PO TBDP","A9270","HCPCS","57237-077-10","NDC","250","RC","","Facility","Outpatient","4","ME","1.47","1.47","","","","1.47","Fee Schedule","","","","","1.47","Fee Schedule","","","","","1.47","Fee Schedule","","","52","","1.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.26","86","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","","52","","1.47","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.86;102% of Medicaid interim rate","1.10","75","","","Percent of Total Billed Charges","neg_dollar:$1.10","1.26","86","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.84;103.5% of Medicaid interim rate","1.47","150","","","Percent of Total Billed Charges","neg_dollar:$2.28;150% of Medicaid interim rate","1.18","80","","","Percent of Total Billed Charges","neg_dollar:$1.18;Percent of Total Billed Charges","1.35","92","","","Percent of Total Billed Charges","neg_dollar:$1.35","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.47","Fee Schedule","","1.00","1.00",""
"METHYLPREDNISOLONE 4 MG PO TABS","A9270","HCPCS","42806-400-01","NDC","250","RC","","Facility","Outpatient","4","ME","0.77","0.77","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","","52","","0.77","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.58","75","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.77","150","","","Percent of Total Billed Charges","neg_dollar:$1.19;150% of Medicaid interim rate","0.62","80","","","Percent of Total Billed Charges","neg_dollar:$0.62;Percent of Total Billed Charges","0.71","92","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.77","Fee Schedule","","1.00","1.00",""
"CHOLESTYRAMINE LIGHT 4 G PO PACK","A9270","HCPCS","68382-529-60","NDC","250","RC","","Facility","Outpatient","4","GM","3.50","3.50","","","","3.50","Fee Schedule","","","","","3.50","Fee Schedule","","","","","3.50","Fee Schedule","","","52","","3.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","52","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","52","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.01","86","","","Percent of Total Billed Charges","neg_dollar:$3.01","2.44","70","","","Percent of Total Billed Charges","neg_dollar:$2.44","","52","","3.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.05;102% of Medicaid interim rate","2.62","75","","","Percent of Total Billed Charges","neg_dollar:$2.62","3.01","86","","","Percent of Total Billed Charges","neg_dollar:$3.01","2.44","70","","","Percent of Total Billed Charges","neg_dollar:$2.44","1.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.99;103.5% of Medicaid interim rate","3.50","150","","","Percent of Total Billed Charges","neg_dollar:$5.41;150% of Medicaid interim rate","2.80","80","","","Percent of Total Billed Charges","neg_dollar:$2.80;Percent of Total Billed Charges","3.22","92","","","Percent of Total Billed Charges","neg_dollar:$3.22","1.82","52","","","Percent of Total Billed Charges","neg_dollar:$1.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.50","Fee Schedule","","1.00","3.00",""
"METHYLPREDNISOLONE 4 MG PO TABS","A9270","HCPCS","00440-7760-21","NDC","250","RC","","Facility","Outpatient","4","ME","1.11","1.11","","","","1.11","Fee Schedule","","","","","1.11","Fee Schedule","","","","","1.11","Fee Schedule","","","52","","1.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","","52","","1.11","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% of Medicaid interim rate","0.83","75","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;103.5% of Medicaid interim rate","1.11","150","","","Percent of Total Billed Charges","neg_dollar:$1.72;150% of Medicaid interim rate","0.89","80","","","Percent of Total Billed Charges","neg_dollar:$0.89;Percent of Total Billed Charges","1.02","92","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.11","Fee Schedule","","1.00","1.00",""
"TIZANIDINE HCL 4 MG PO TABS","A9270","HCPCS","50268-760-11","NDC","250","RC","","Facility","Outpatient","4","ME","1.80","1.80","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","","52","","1.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;102% of Medicaid interim rate","1.35","75","","","Percent of Total Billed Charges","neg_dollar:$1.35","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;103.5% of Medicaid interim rate","1.80","150","","","Percent of Total Billed Charges","neg_dollar:$2.78;150% of Medicaid interim rate","1.44","80","","","Percent of Total Billed Charges","neg_dollar:$1.44;Percent of Total Billed Charges","1.65","92","","","Percent of Total Billed Charges","neg_dollar:$1.65","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.80","Fee Schedule","","1.00","1.00",""
"DOXAZOSIN MESYLATE 4 MG PO TABS","A9270","HCPCS","68084-862-11","NDC","250","RC","","Facility","Outpatient","4","ME","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","","52","","1.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.70","Fee Schedule","","1.00","1.00",""
"ONDANSETRON 4 MG PO TBDP","A9270","HCPCS","57237-077-10","NDC","637","RC","","Facility","Outpatient","4","ME","2.36","2.36","","","","2.36","Fee Schedule","","","","","2.36","Fee Schedule","101% of Medicare Fee Schedule","","","","2.36","Fee Schedule","","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.03","86","","","Percent of Total Billed Charges","neg_dollar:$2.03","1.65","70","","","Percent of Total Billed Charges","neg_dollar:$1.65","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.38;102% of Medicaid interim rate","1.77","75","","","Percent of Total Billed Charges","neg_dollar:$1.77","2.03","86","","","Percent of Total Billed Charges","neg_dollar:$2.03","1.65","70","","","Percent of Total Billed Charges","neg_dollar:$1.65","1.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.34;103.5% of Medicaid interim rate","2.36","150","","","Percent of Total Billed Charges","neg_dollar:$3.65;150% of Medicaid interim rate","1.88","80","","","Percent of Total Billed Charges","neg_dollar:$1.88;Percent of Total Billed Charges","2.17","92","","","Percent of Total Billed Charges","neg_dollar:$2.17","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"TIZANIDINE HCL 4 MG PO TABS","A9270","HCPCS","50268-760-15","NDC","637","RC","","Facility","Outpatient","4","ME","1.80","1.80","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","101% of Medicare Fee Schedule","","","","1.80","Fee Schedule","","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;102% of Medicaid interim rate","1.35","75","","","Percent of Total Billed Charges","neg_dollar:$1.35","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;103.5% of Medicaid interim rate","1.80","150","","","Percent of Total Billed Charges","neg_dollar:$2.78;150% of Medicaid interim rate","1.44","80","","","Percent of Total Billed Charges","neg_dollar:$1.44;Percent of Total Billed Charges","1.65","92","","","Percent of Total Billed Charges","neg_dollar:$1.65","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CHOLESTYRAMINE LIGHT 4 G PO PACK","A9270","HCPCS","68382-529-60","NDC","637","RC","","Facility","Outpatient","1","EA","3.50","3.50","","","","3.50","Fee Schedule","","","","","3.50","Fee Schedule","101% of Medicare Fee Schedule","","","","3.50","Fee Schedule","","1.82","52","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.01","86","","","Percent of Total Billed Charges","neg_dollar:$3.01","2.44","70","","","Percent of Total Billed Charges","neg_dollar:$2.44","1.82","52","","","Percent of Total Billed Charges","neg_dollar:$1.82;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.05;102% of Medicaid interim rate","2.62","75","","","Percent of Total Billed Charges","neg_dollar:$2.62","3.01","86","","","Percent of Total Billed Charges","neg_dollar:$3.01","2.44","70","","","Percent of Total Billed Charges","neg_dollar:$2.44","1.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.99;103.5% of Medicaid interim rate","3.50","150","","","Percent of Total Billed Charges","neg_dollar:$5.41;150% of Medicaid interim rate","2.80","80","","","Percent of Total Billed Charges","neg_dollar:$2.80;Percent of Total Billed Charges","3.22","92","","","Percent of Total Billed Charges","neg_dollar:$3.22","1.82","52","","","Percent of Total Billed Charges","neg_dollar:$1.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","52","","","Percent of Total Billed Charges","neg_dollar:$1.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"TIZANIDINE HCL 4 MG PO TABS","A9270","HCPCS","68084-645-11","NDC","637","RC","","Facility","Outpatient","4","ME","1.80","1.80","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","101% of Medicare Fee Schedule","","","","1.80","Fee Schedule","","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;102% of Medicaid interim rate","1.35","75","","","Percent of Total Billed Charges","neg_dollar:$1.35","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;103.5% of Medicaid interim rate","1.80","150","","","Percent of Total Billed Charges","neg_dollar:$2.78;150% of Medicaid interim rate","1.44","80","","","Percent of Total Billed Charges","neg_dollar:$1.44;Percent of Total Billed Charges","1.65","92","","","Percent of Total Billed Charges","neg_dollar:$1.65","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DOXAZOSIN MESYLATE 4 MG PO TABS","A9270","HCPCS","68084-862-11","NDC","637","RC","","Facility","Outpatient","4","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","101% of Medicare Fee Schedule","","","","1.60","Fee Schedule","","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TIZANIDINE HCL 4 MG PO TABS","A9270","HCPCS","50268-760-11","NDC","637","RC","","Facility","Outpatient","4","ME","1.80","1.80","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","101% of Medicare Fee Schedule","","","","1.80","Fee Schedule","","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;102% of Medicaid interim rate","1.35","75","","","Percent of Total Billed Charges","neg_dollar:$1.35","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;103.5% of Medicaid interim rate","1.80","150","","","Percent of Total Billed Charges","neg_dollar:$2.78;150% of Medicaid interim rate","1.44","80","","","Percent of Total Billed Charges","neg_dollar:$1.44;Percent of Total Billed Charges","1.65","92","","","Percent of Total Billed Charges","neg_dollar:$1.65","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TAKE HOME ONDANSETRON ODT 4 MG PO TBDP (QTY:FOUR)","A9270","HCPCS","68462-157-13","NDC","253","RC","","Facility","Outpatient","1","UN","12.55","12.55","12.55","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","6.52","52","","","Percent of Total Billed Charges","neg_dollar:$6.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","12.55","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","6.52","52","","","Percent of Total Billed Charges","neg_dollar:$6.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.52","52","","","Percent of Total Billed Charges","neg_dollar:$6.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.52","52","","","Percent of Total Billed Charges","neg_dollar:$6.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.79","86","","","Percent of Total Billed Charges","neg_dollar:$10.79","8.78","70","","","Percent of Total Billed Charges","neg_dollar:$8.78","6.52","52","","","Percent of Total Billed Charges","neg_dollar:$6.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.37;102% of Medicaid interim rate","9.41","75","","","Percent of Total Billed Charges","neg_dollar:$9.41","10.79","86","","","Percent of Total Billed Charges","neg_dollar:$10.79","8.78","70","","","Percent of Total Billed Charges","neg_dollar:$8.78","7.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.15;103.5% of Medicaid interim rate","12.55","150","","","Percent of Total Billed Charges","neg_dollar:$19.40;150% of Medicaid interim rate","10.04","80","","","Percent of Total Billed Charges","neg_dollar:$10.04;Percent of Total Billed Charges","11.54","92","","","Percent of Total Billed Charges","neg_dollar:$11.54","6.52","52","","","Percent of Total Billed Charges","neg_dollar:$6.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.52","52","","","Percent of Total Billed Charges","neg_dollar:$6.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","12.00",""
"TAKE HOME ONDANSETRON ODT 4 MG PO TBDP (QTY:FOUR)","A9270","HCPCS","68462-157-13","NDC","250","RC","","Facility","Outpatient","1","UN","12.55","12.55","","","","12.55","Fee Schedule","","","","","12.55","Fee Schedule","","","","","12.55","Fee Schedule","","","52","","12.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.52","52","","","Percent of Total Billed Charges","neg_dollar:$6.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.52","52","","","Percent of Total Billed Charges","neg_dollar:$6.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.79","86","","","Percent of Total Billed Charges","neg_dollar:$10.79","8.78","70","","","Percent of Total Billed Charges","neg_dollar:$8.78","","52","","12.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.37;102% of Medicaid interim rate","9.41","75","","","Percent of Total Billed Charges","neg_dollar:$9.41","10.79","86","","","Percent of Total Billed Charges","neg_dollar:$10.79","8.78","70","","","Percent of Total Billed Charges","neg_dollar:$8.78","7.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.15;103.5% of Medicaid interim rate","12.55","150","","","Percent of Total Billed Charges","neg_dollar:$19.40;150% of Medicaid interim rate","10.04","80","","","Percent of Total Billed Charges","neg_dollar:$10.04;Percent of Total Billed Charges","11.54","92","","","Percent of Total Billed Charges","neg_dollar:$11.54","6.52","52","","","Percent of Total Billed Charges","neg_dollar:$6.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.55","Fee Schedule","","6.00","12.00",""
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","A9270","HCPCS","50268-639-11","NDC","250","RC","","Facility","Outpatient","40","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"FUROSEMIDE 40 MG PO TABS","A9270","HCPCS","00904-7178-61","NDC","250","RC","","Facility","Outpatient","40","ME","0.64","0.64","","","","0.64","Fee Schedule","","","","","0.64","Fee Schedule","","","","","0.64","Fee Schedule","","","52","","0.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","","52","","0.64","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% of Medicaid interim rate","0.48","75","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","0.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.36;103.5% of Medicaid interim rate","0.64","150","","","Percent of Total Billed Charges","neg_dollar:$0.99;150% of Medicaid interim rate","0.51","80","","","Percent of Total Billed Charges","neg_dollar:$0.51;Percent of Total Billed Charges","0.59","92","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.64","Fee Schedule","","1.00","1.00",""
"FUROSEMIDE 40 MG PO TABS","A9270","HCPCS","00054-8299-25","NDC","250","RC","","Facility","Outpatient","40","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% of Medicaid interim rate","0.79","75","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.63;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.97","92","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"GLUCOSE 40 % PO GEL","A9270","HCPCS","00574-06915","NDC","250","RC","","Facility","Outpatient","40","EA","14","14.00","","","","14.00","Fee Schedule","","","","","14.00","Fee Schedule","","","","","14.00","Fee Schedule","","","52","","14.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.28","52","","","Percent of Total Billed Charges","neg_dollar:$7.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.28","52","","","Percent of Total Billed Charges","neg_dollar:$7.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.04","86","","","Percent of Total Billed Charges","neg_dollar:$12.04","9.79","70","","","Percent of Total Billed Charges","neg_dollar:$9.79","","52","","14.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.22;102% of Medicaid interim rate","10.50","75","","","Percent of Total Billed Charges","neg_dollar:$10.50","12.04","86","","","Percent of Total Billed Charges","neg_dollar:$12.04","9.79","70","","","Percent of Total Billed Charges","neg_dollar:$9.79","7.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.97;103.5% of Medicaid interim rate","14.00","150","","","Percent of Total Billed Charges","neg_dollar:$21.64;150% of Medicaid interim rate","11.20","80","","","Percent of Total Billed Charges","neg_dollar:$11.20;Percent of Total Billed Charges","12.88","92","","","Percent of Total Billed Charges","neg_dollar:$12.88","7.28","52","","","Percent of Total Billed Charges","neg_dollar:$7.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","14.00","Fee Schedule","","7.00","14.00",""
"ATORVASTATIN CALCIUM 40 MG PO TABS","A9270","HCPCS","68084-099-11","NDC","250","RC","","Facility","Outpatient","40","ME","1.29","1.29","","","","1.29","Fee Schedule","","","","","1.29","Fee Schedule","","","","","1.29","Fee Schedule","","","52","","1.29","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.29","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;103.5% of Medicaid interim rate","1.29","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.03","80","","","Percent of Total Billed Charges","neg_dollar:$1.03;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.29","Fee Schedule","","1.00","1.00",""
"GLUCOSE 40 % PO GEL","A9270","HCPCS","00574-06915","NDC","637","RC","","Facility","Outpatient","40","UN","14","14.00","","","","14.00","Fee Schedule","","","","","14.00","Fee Schedule","101% of Medicare Fee Schedule","","","","14.00","Fee Schedule","","7.28","52","","","Percent of Total Billed Charges","neg_dollar:$7.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","14.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","14.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.04","86","","","Percent of Total Billed Charges","neg_dollar:$12.04","9.79","70","","","Percent of Total Billed Charges","neg_dollar:$9.79","7.28","52","","","Percent of Total Billed Charges","neg_dollar:$7.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","8.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.22;102% of Medicaid interim rate","10.50","75","","","Percent of Total Billed Charges","neg_dollar:$10.50","12.04","86","","","Percent of Total Billed Charges","neg_dollar:$12.04","9.79","70","","","Percent of Total Billed Charges","neg_dollar:$9.79","7.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.97;103.5% of Medicaid interim rate","14.00","150","","","Percent of Total Billed Charges","neg_dollar:$21.64;150% of Medicaid interim rate","11.20","80","","","Percent of Total Billed Charges","neg_dollar:$11.20;Percent of Total Billed Charges","12.88","92","","","Percent of Total Billed Charges","neg_dollar:$12.88","7.28","52","","","Percent of Total Billed Charges","neg_dollar:$7.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.28","52","","","Percent of Total Billed Charges","neg_dollar:$7.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","14.00",""
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","A9270","HCPCS","50268-639-15","NDC","250","RC","","Facility","Outpatient","40","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","A9270","HCPCS","50268-639-11","NDC","637","RC","","Facility","Outpatient","40","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ATORVASTATIN CALCIUM 40 MG PO TABS","A9270","HCPCS","68084-099-11","NDC","637","RC","","Facility","Outpatient","40","ME","1.37","1.37","","","","1.37","Fee Schedule","","","","","1.37","Fee Schedule","101% of Medicare Fee Schedule","","","","1.37","Fee Schedule","","0.71","52","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","86","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.95","70","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.71","52","","","Percent of Total Billed Charges","neg_dollar:$0.71;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% of Medicaid interim rate","1.02","75","","","Percent of Total Billed Charges","neg_dollar:$1.02","1.17","86","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.95","70","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.78;103.5% of Medicaid interim rate","1.37","150","","","Percent of Total Billed Charges","neg_dollar:$2.11;150% of Medicaid interim rate","1.09","80","","","Percent of Total Billed Charges","neg_dollar:$1.09;Percent of Total Billed Charges","1.26","92","","","Percent of Total Billed Charges","neg_dollar:$1.26","0.71","52","","","Percent of Total Billed Charges","neg_dollar:$0.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","52","","","Percent of Total Billed Charges","neg_dollar:$0.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FUROSEMIDE 40 MG PO TABS","A9270","HCPCS","00904-7178-61","NDC","637","RC","","Facility","Outpatient","40","ME","0.60","0.60","","","","0.60","Fee Schedule","","","","","0.60","Fee Schedule","101% of Medicare Fee Schedule","","","","0.60","Fee Schedule","","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% of Medicaid interim rate","0.44","75","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.34;103.5% of Medicaid interim rate","0.60","150","","","Percent of Total Billed Charges","neg_dollar:$0.92;150% of Medicaid interim rate","0.48","80","","","Percent of Total Billed Charges","neg_dollar:$0.48;Percent of Total Billed Charges","0.55","92","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ATORVASTATIN CALCIUM 40 MG PO TABS","A9270","HCPCS","68084-099-01","NDC","250","RC","","Facility","Outpatient","40","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.55","Fee Schedule","","1.00","1.00",""
"FUROSEMIDE 40 MG PO TABS","A9270","HCPCS","00054-8299-25","NDC","637","RC","","Facility","Outpatient","40","ME","0.78","0.78","","","","0.78","Fee Schedule","","","","","0.78","Fee Schedule","101% of Medicare Fee Schedule","","","","0.78","Fee Schedule","","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.78","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.78","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","86","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.58","75","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.67","86","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.78","150","","","Percent of Total Billed Charges","neg_dollar:$1.21;150% of Medicaid interim rate","0.62","80","","","Percent of Total Billed Charges","neg_dollar:$0.62;Percent of Total Billed Charges","0.72","92","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","A9270","HCPCS","50268-639-15","NDC","637","RC","","Facility","Outpatient","40","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"IBUPROFEN 400 MG PO TABS","A9270","HCPCS","00904-5853-61","NDC","250","RC","","Facility","Outpatient","400","ME","0.79","0.79","","","","0.79","Fee Schedule","","","","","0.79","Fee Schedule","","","","","0.79","Fee Schedule","","","52","","0.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","","52","","0.79","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.59","75","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.79","150","","","Percent of Total Billed Charges","neg_dollar:$1.22;150% of Medicaid interim rate","0.63","80","","","Percent of Total Billed Charges","neg_dollar:$0.63;Percent of Total Billed Charges","0.72","92","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.79","Fee Schedule","","1.00","1.00",""
"ACYCLOVIR 400 MG PO TABS","A9270","HCPCS","50268-061-11","NDC","250","RC","","Facility","Outpatient","400","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP","A9270","HCPCS","60687-429-45","NDC","250","RC","","Facility","Outpatient","5","ML","2.98","2.98","","","","2.98","Fee Schedule","","","","","2.98","Fee Schedule","","","","","2.98","Fee Schedule","","","52","","2.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.55","52","","","Percent of Total Billed Charges","neg_dollar:$1.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.55","52","","","Percent of Total Billed Charges","neg_dollar:$1.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.57","86","","","Percent of Total Billed Charges","neg_dollar:$2.57","2.09","70","","","Percent of Total Billed Charges","neg_dollar:$2.09","","52","","2.98","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.75;102% of Medicaid interim rate","2.24","75","","","Percent of Total Billed Charges","neg_dollar:$2.24","2.57","86","","","Percent of Total Billed Charges","neg_dollar:$2.57","2.09","70","","","Percent of Total Billed Charges","neg_dollar:$2.09","1.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.70;103.5% of Medicaid interim rate","2.98","150","","","Percent of Total Billed Charges","neg_dollar:$4.62;150% of Medicaid interim rate","2.39","80","","","Percent of Total Billed Charges","neg_dollar:$2.39;Percent of Total Billed Charges","2.74","92","","","Percent of Total Billed Charges","neg_dollar:$2.74","1.55","52","","","Percent of Total Billed Charges","neg_dollar:$1.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.98","Fee Schedule","","1.00","2.00",""
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP","A9270","HCPCS","69339-153-01","NDC","250","RC","","Facility","Outpatient","5","ML","3.43","3.43","","","","3.43","Fee Schedule","","","","","3.43","Fee Schedule","","","","","3.43","Fee Schedule","","","52","","3.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.78","52","","","Percent of Total Billed Charges","neg_dollar:$1.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.78","52","","","Percent of Total Billed Charges","neg_dollar:$1.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.94","86","","","Percent of Total Billed Charges","neg_dollar:$2.94","2.40","70","","","Percent of Total Billed Charges","neg_dollar:$2.40","","52","","3.43","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.01;102% of Medicaid interim rate","2.57","75","","","Percent of Total Billed Charges","neg_dollar:$2.57","2.94","86","","","Percent of Total Billed Charges","neg_dollar:$2.94","2.40","70","","","Percent of Total Billed Charges","neg_dollar:$2.40","1.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.95;103.5% of Medicaid interim rate","3.43","150","","","Percent of Total Billed Charges","neg_dollar:$5.30;150% of Medicaid interim rate","2.74","80","","","Percent of Total Billed Charges","neg_dollar:$2.74;Percent of Total Billed Charges","3.15","92","","","Percent of Total Billed Charges","neg_dollar:$3.15","1.78","52","","","Percent of Total Billed Charges","neg_dollar:$1.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.43","Fee Schedule","","1.00","3.00",""
"GABAPENTIN 400 MG PO CAPS","A9270","HCPCS","00904-6667-61","NDC","637","RC","","Facility","Outpatient","400","ME","0.71","0.71","","","","0.71","Fee Schedule","","","","","0.71","Fee Schedule","101% of Medicare Fee Schedule","","","","0.71","Fee Schedule","","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","86","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.49","70","","","Percent of Total Billed Charges","neg_dollar:$0.49","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% of Medicaid interim rate","0.53","75","","","Percent of Total Billed Charges","neg_dollar:$0.53","0.61","86","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.49","70","","","Percent of Total Billed Charges","neg_dollar:$0.49","0.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.40;103.5% of Medicaid interim rate","0.71","150","","","Percent of Total Billed Charges","neg_dollar:$1.10;150% of Medicaid interim rate","0.57","80","","","Percent of Total Billed Charges","neg_dollar:$0.57;Percent of Total Billed Charges","0.65","92","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"GABAPENTIN 400 MG PO CAPS","A9270","HCPCS","00904-6667-61","NDC","250","RC","","Facility","Outpatient","400","ME","1.18","1.18","","","","1.18","Fee Schedule","","","","","1.18","Fee Schedule","","","","","1.18","Fee Schedule","","","52","","1.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","86","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.83","70","","","Percent of Total Billed Charges","neg_dollar:$0.83","","52","","1.18","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.02","86","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.83","70","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;103.5% of Medicaid interim rate","1.18","150","","","Percent of Total Billed Charges","neg_dollar:$1.83;150% of Medicaid interim rate","0.95","80","","","Percent of Total Billed Charges","neg_dollar:$0.95;Percent of Total Billed Charges","1.09","92","","","Percent of Total Billed Charges","neg_dollar:$1.09","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.18","Fee Schedule","","1.00","1.00",""
"ACYCLOVIR 400 MG PO TABS","A9270","HCPCS","50268-061-11","NDC","637","RC","","Facility","Outpatient","400","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","101% of Medicare Fee Schedule","","","","1.35","Fee Schedule","","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP","A9270","HCPCS","60687-429-45","NDC","637","RC","","Facility","Outpatient","5","ML","3.45","3.45","","","","3.45","Fee Schedule","","","","","3.45","Fee Schedule","101% of Medicare Fee Schedule","","","","3.45","Fee Schedule","","1.79","52","","","Percent of Total Billed Charges","neg_dollar:$1.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.96","86","","","Percent of Total Billed Charges","neg_dollar:$2.96","2.41","70","","","Percent of Total Billed Charges","neg_dollar:$2.41","1.79","52","","","Percent of Total Billed Charges","neg_dollar:$1.79;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.02;102% of Medicaid interim rate","2.58","75","","","Percent of Total Billed Charges","neg_dollar:$2.58","2.96","86","","","Percent of Total Billed Charges","neg_dollar:$2.96","2.41","70","","","Percent of Total Billed Charges","neg_dollar:$2.41","1.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.96;103.5% of Medicaid interim rate","3.45","150","","","Percent of Total Billed Charges","neg_dollar:$5.33;150% of Medicaid interim rate","2.76","80","","","Percent of Total Billed Charges","neg_dollar:$2.76;Percent of Total Billed Charges","3.17","92","","","Percent of Total Billed Charges","neg_dollar:$3.17","1.79","52","","","Percent of Total Billed Charges","neg_dollar:$1.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.79","52","","","Percent of Total Billed Charges","neg_dollar:$1.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"IBUPROFEN 400 MG PO TABS","A9270","HCPCS","00904-5853-61","NDC","637","RC","","Facility","Outpatient","400","ME","0.55","0.55","","","","0.55","Fee Schedule","","","","","0.55","Fee Schedule","101% of Medicare Fee Schedule","","","","0.55","Fee Schedule","","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","86","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","70","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% of Medicaid interim rate","0.41","75","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.48","86","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","70","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.31;103.5% of Medicaid interim rate","0.55","150","","","Percent of Total Billed Charges","neg_dollar:$0.86;150% of Medicaid interim rate","0.44","80","","","Percent of Total Billed Charges","neg_dollar:$0.44;Percent of Total Billed Charges","0.51","92","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"IBUPROFEN 400 MG PO TABS","A9270","HCPCS","60687-446-11","NDC","637","RC","","Facility","Outpatient","400","ME","0.15","0.15","","","","0.15","Fee Schedule","","","","","0.15","Fee Schedule","101% of Medicare Fee Schedule","","","","0.15","Fee Schedule","","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.12","86","","","Percent of Total Billed Charges","neg_dollar:$0.12","0.10","70","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.08;102% of Medicaid interim rate","0.11","75","","","Percent of Total Billed Charges","neg_dollar:$0.11","0.12","86","","","Percent of Total Billed Charges","neg_dollar:$0.12","0.10","70","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.08;103.5% of Medicaid interim rate","0.15","150","","","Percent of Total Billed Charges","neg_dollar:$0.23;150% of Medicaid interim rate","0.12","80","","","Percent of Total Billed Charges","neg_dollar:$0.12;Percent of Total Billed Charges","0.13","92","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP","A9270","HCPCS","69339-153-01","NDC","637","RC","","Facility","Outpatient","5","ML","3.38","3.38","","","","3.38","Fee Schedule","","","","","3.38","Fee Schedule","101% of Medicare Fee Schedule","","","","3.38","Fee Schedule","","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.91","86","","","Percent of Total Billed Charges","neg_dollar:$2.91","2.37","70","","","Percent of Total Billed Charges","neg_dollar:$2.37","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.99;102% of Medicaid interim rate","2.54","75","","","Percent of Total Billed Charges","neg_dollar:$2.54","2.91","86","","","Percent of Total Billed Charges","neg_dollar:$2.91","2.37","70","","","Percent of Total Billed Charges","neg_dollar:$2.37","1.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.93;103.5% of Medicaid interim rate","3.38","150","","","Percent of Total Billed Charges","neg_dollar:$5.23;150% of Medicaid interim rate","2.71","80","","","Percent of Total Billed Charges","neg_dollar:$2.71;Percent of Total Billed Charges","3.11","92","","","Percent of Total Billed Charges","neg_dollar:$3.11","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"MAGNESIUM OXIDE 400 MG WRAPPER","A9270","HCPCS","10006-70028","NDC","250","RC","","Facility","Outpatient","1","EA","1.08","1.08","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","","","52","","1.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","","52","","1.08","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;103.5% of Medicaid interim rate","1.08","150","","","Percent of Total Billed Charges","neg_dollar:$1.67;150% of Medicaid interim rate","0.86","80","","","Percent of Total Billed Charges","neg_dollar:$0.86;Percent of Total Billed Charges","0.99","92","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.08","Fee Schedule","","1.00","1.00",""
"MAGNESIUM OXIDE 400 MG WRAPPER","A9270","HCPCS","10006-70028","NDC","637","RC","","Facility","Outpatient","1","EA","1.07","1.07","","","","1.07","Fee Schedule","","","","","1.07","Fee Schedule","101% of Medicare Fee Schedule","","","","1.07","Fee Schedule","","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% of Medicaid interim rate","0.80","75","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;103.5% of Medicaid interim rate","1.07","150","","","Percent of Total Billed Charges","neg_dollar:$1.66;150% of Medicaid interim rate","0.86","80","","","Percent of Total Billed Charges","neg_dollar:$0.86;Percent of Total Billed Charges","0.98","92","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SACUBITRIL-VALSARTAN 49-51 MG PO TABS","A9270","HCPCS","00078-0777-20","NDC","250","RC","","Facility","Outpatient","1","EA","14.80","14.80","","","","14.80","Fee Schedule","","","","","14.80","Fee Schedule","","","","","14.80","Fee Schedule","","","52","","14.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.69","52","","","Percent of Total Billed Charges","neg_dollar:$7.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.69","52","","","Percent of Total Billed Charges","neg_dollar:$7.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.72","86","","","Percent of Total Billed Charges","neg_dollar:$12.72","10.36","70","","","Percent of Total Billed Charges","neg_dollar:$10.36","","52","","14.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.69;102% of Medicaid interim rate","11.10","75","","","Percent of Total Billed Charges","neg_dollar:$11.10","12.72","86","","","Percent of Total Billed Charges","neg_dollar:$12.72","10.36","70","","","Percent of Total Billed Charges","neg_dollar:$10.36","8.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.43;103.5% of Medicaid interim rate","14.80","150","","","Percent of Total Billed Charges","neg_dollar:$22.88;150% of Medicaid interim rate","11.84","80","","","Percent of Total Billed Charges","neg_dollar:$11.84;Percent of Total Billed Charges","13.61","92","","","Percent of Total Billed Charges","neg_dollar:$13.61","7.69","52","","","Percent of Total Billed Charges","neg_dollar:$7.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","14.80","Fee Schedule","","7.00","14.00",""
"GLIPIZIDE 5 MG PO TABS","A9270","HCPCS","50268-361-11","NDC","250","RC","","Facility","Outpatient","5","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"OXYBUTYNIN CHLORIDE ER 5 MG PO TB24","A9270","HCPCS","50268-627-11","NDC","250","RC","","Facility","Outpatient","5","ME","4.11","4.11","","","","4.11","Fee Schedule","","","","","4.11","Fee Schedule","","","","","4.11","Fee Schedule","","","52","","4.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.13","52","","","Percent of Total Billed Charges","neg_dollar:$2.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.13","52","","","Percent of Total Billed Charges","neg_dollar:$2.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.53","86","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.87","70","","","Percent of Total Billed Charges","neg_dollar:$2.87","","52","","4.11","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.41;102% of Medicaid interim rate","3.08","75","","","Percent of Total Billed Charges","neg_dollar:$3.08","3.53","86","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.87","70","","","Percent of Total Billed Charges","neg_dollar:$2.87","2.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.34;103.5% of Medicaid interim rate","4.11","150","","","Percent of Total Billed Charges","neg_dollar:$6.35;150% of Medicaid interim rate","3.28","80","","","Percent of Total Billed Charges","neg_dollar:$3.28;Percent of Total Billed Charges","3.78","92","","","Percent of Total Billed Charges","neg_dollar:$3.78","2.13","52","","","Percent of Total Billed Charges","neg_dollar:$2.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.11","Fee Schedule","","2.00","4.00",""
"ENALAPRIL MALEATE 5 MG PO TABS","A9270","HCPCS","43547-546-10","NDC","250","RC","","Facility","Outpatient","5","ME","0.51","0.51","","","","0.51","Fee Schedule","","","","","0.51","Fee Schedule","","","","","0.51","Fee Schedule","","","52","","0.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","86","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","","52","","0.51","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.30;102% of Medicaid interim rate","0.38","75","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.44","86","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;103.5% of Medicaid interim rate","0.51","150","","","Percent of Total Billed Charges","neg_dollar:$0.79;150% of Medicaid interim rate","0.41","80","","","Percent of Total Billed Charges","neg_dollar:$0.41;Percent of Total Billed Charges","0.47","92","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.51","Fee Schedule","","1.00","1.00",""
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","A9270","HCPCS","50268-684-11","NDC","250","RC","","Facility","Outpatient","5","ME","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","","52","","2.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.05","Fee Schedule","","1.00","2.00",""
"APIXABAN 5 MG PO TABS","A9270","HCPCS","00003-0894-21","NDC","250","RC","","Facility","Outpatient","5","ME","10.65","10.65","","","","10.65","Fee Schedule","","","","","10.65","Fee Schedule","","","","","10.65","Fee Schedule","","","52","","10.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.16","86","","","Percent of Total Billed Charges","neg_dollar:$9.16","7.45","70","","","Percent of Total Billed Charges","neg_dollar:$7.45","","52","","10.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.25;102% of Medicaid interim rate","7.98","75","","","Percent of Total Billed Charges","neg_dollar:$7.98","9.16","86","","","Percent of Total Billed Charges","neg_dollar:$9.16","7.45","70","","","Percent of Total Billed Charges","neg_dollar:$7.45","6.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.07;103.5% of Medicaid interim rate","10.65","150","","","Percent of Total Billed Charges","neg_dollar:$16.46;150% of Medicaid interim rate","8.52","80","","","Percent of Total Billed Charges","neg_dollar:$8.52;Percent of Total Billed Charges","9.80","92","","","Percent of Total Billed Charges","neg_dollar:$9.80","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.65","Fee Schedule","","5.00","10.00",""
"OXYCODONE HCL 5 MG PO TABS","A9270","HCPCS","10702-018-01","NDC","250","RC","","Facility","Outpatient","5","ME","0.82","0.82","","","","0.82","Fee Schedule","","","","","0.82","Fee Schedule","","","","","0.82","Fee Schedule","","","52","","0.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","86","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","","52","","0.82","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% of Medicaid interim rate","0.61","75","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.71","86","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;103.5% of Medicaid interim rate","0.82","150","","","Percent of Total Billed Charges","neg_dollar:$1.27;150% of Medicaid interim rate","0.66","80","","","Percent of Total Billed Charges","neg_dollar:$0.66;Percent of Total Billed Charges","0.76","92","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.82","Fee Schedule","","1.00","1.00",""
"OLANZAPINE 5 MG PO TABS","A9270","HCPCS","60505-3111-0","NDC","250","RC","","Facility","Outpatient","5","ME","0.62","0.62","","","","0.62","Fee Schedule","","","","","0.62","Fee Schedule","","","","","0.62","Fee Schedule","","","52","","0.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","86","","","Percent of Total Billed Charges","neg_dollar:$0.53","0.43","70","","","Percent of Total Billed Charges","neg_dollar:$0.43","","52","","0.62","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.36;102% of Medicaid interim rate","0.46","75","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.53","86","","","Percent of Total Billed Charges","neg_dollar:$0.53","0.43","70","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.35;103.5% of Medicaid interim rate","0.62","150","","","Percent of Total Billed Charges","neg_dollar:$0.96;150% of Medicaid interim rate","0.49","80","","","Percent of Total Billed Charges","neg_dollar:$0.49;Percent of Total Billed Charges","0.57","92","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.62","Fee Schedule","","1.00","1.00",""
"MIDODRINE HCL 5 MG PO TABS","A9270","HCPCS","60687-398-11","NDC","250","RC","","Facility","Outpatient","5","ME","1.59","1.59","","","","1.59","Fee Schedule","","","","","1.59","Fee Schedule","","","","","1.59","Fee Schedule","","","52","","1.59","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.59","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.19","75","","","Percent of Total Billed Charges","neg_dollar:$1.19","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.90;103.5% of Medicaid interim rate","1.59","150","","","Percent of Total Billed Charges","neg_dollar:$2.46;150% of Medicaid interim rate","1.27","80","","","Percent of Total Billed Charges","neg_dollar:$1.27;Percent of Total Billed Charges","1.46","92","","","Percent of Total Billed Charges","neg_dollar:$1.46","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.59","Fee Schedule","","1.00","1.00",""
"AMILORIDE HCL 5 MG PO TABS","A9270","HCPCS","00574-0292-01","NDC","250","RC","","Facility","Outpatient","5","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"LISINOPRIL 5 MG PO TABS","A9270","HCPCS","00904-6797-61","NDC","250","RC","","Facility","Outpatient","5","ME","0.75","0.75","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","","","52","","0.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","","52","","0.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% of Medicaid interim rate","0.56","75","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.43;103.5% of Medicaid interim rate","0.75","150","","","Percent of Total Billed Charges","neg_dollar:$1.16;150% of Medicaid interim rate","0.60","80","","","Percent of Total Billed Charges","neg_dollar:$0.60;Percent of Total Billed Charges","0.69","92","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.75","Fee Schedule","","1.00","1.00",""
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","A9270","HCPCS","50268-684-15","NDC","250","RC","","Facility","Outpatient","5","ME","1.85","1.85","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","","52","","1.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;103.5% of Medicaid interim rate","1.85","150","","","Percent of Total Billed Charges","neg_dollar:$2.86;150% of Medicaid interim rate","1.48","80","","","Percent of Total Billed Charges","neg_dollar:$1.48;Percent of Total Billed Charges","1.70","92","","","Percent of Total Billed Charges","neg_dollar:$1.70","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.85","Fee Schedule","","1.00","1.00",""
"LIDOCAINE 5 % EX PTCH","A9270","HCPCS","00591-3525-11","NDC","250","RC","","Facility","Outpatient","1","EA","4.43","4.43","","","","4.43","Fee Schedule","","","","","4.43","Fee Schedule","","","","","4.43","Fee Schedule","","","52","","4.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.30","52","","","Percent of Total Billed Charges","neg_dollar:$2.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.30","52","","","Percent of Total Billed Charges","neg_dollar:$2.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.81","86","","","Percent of Total Billed Charges","neg_dollar:$3.81","3.10","70","","","Percent of Total Billed Charges","neg_dollar:$3.10","","52","","4.43","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.60;102% of Medicaid interim rate","3.32","75","","","Percent of Total Billed Charges","neg_dollar:$3.32","3.81","86","","","Percent of Total Billed Charges","neg_dollar:$3.81","3.10","70","","","Percent of Total Billed Charges","neg_dollar:$3.10","2.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.53;103.5% of Medicaid interim rate","4.43","150","","","Percent of Total Billed Charges","neg_dollar:$6.86;150% of Medicaid interim rate","3.55","80","","","Percent of Total Billed Charges","neg_dollar:$3.55;Percent of Total Billed Charges","4.08","92","","","Percent of Total Billed Charges","neg_dollar:$4.08","2.30","52","","","Percent of Total Billed Charges","neg_dollar:$2.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.43","Fee Schedule","","2.00","4.00",""
"WARFARIN SODIUM 5 MG PO TABS","A9270","HCPCS","00832-1216-89","NDC","250","RC","","Facility","Outpatient","5","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"OXYBUTYNIN CHLORIDE ER 5 MG PO TB24","A9270","HCPCS","50268-627-15","NDC","250","RC","","Facility","Outpatient","5","ME","4.20","4.20","","","","4.20","Fee Schedule","","","","","4.20","Fee Schedule","","","","","4.20","Fee Schedule","","","52","","4.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.18","52","","","Percent of Total Billed Charges","neg_dollar:$2.18;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.18","52","","","Percent of Total Billed Charges","neg_dollar:$2.18;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.61","86","","","Percent of Total Billed Charges","neg_dollar:$3.61","2.94","70","","","Percent of Total Billed Charges","neg_dollar:$2.94","","52","","4.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.46;102% of Medicaid interim rate","3.15","75","","","Percent of Total Billed Charges","neg_dollar:$3.15","3.61","86","","","Percent of Total Billed Charges","neg_dollar:$3.61","2.94","70","","","Percent of Total Billed Charges","neg_dollar:$2.94","2.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.39;103.5% of Medicaid interim rate","4.20","150","","","Percent of Total Billed Charges","neg_dollar:$6.49;150% of Medicaid interim rate","3.36","80","","","Percent of Total Billed Charges","neg_dollar:$3.36;Percent of Total Billed Charges","3.86","92","","","Percent of Total Billed Charges","neg_dollar:$3.86","2.18","52","","","Percent of Total Billed Charges","neg_dollar:$2.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.20","Fee Schedule","","2.00","4.00",""
"LIDOCAINE 5 % EX PTCH","A9270","HCPCS","00603-1880-16","NDC","250","RC","","Facility","Outpatient","1","EA","4.55","4.55","","","","4.55","Fee Schedule","","","","","4.55","Fee Schedule","","","","","4.55","Fee Schedule","","","52","","4.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.36","52","","","Percent of Total Billed Charges","neg_dollar:$2.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.36","52","","","Percent of Total Billed Charges","neg_dollar:$2.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.91","86","","","Percent of Total Billed Charges","neg_dollar:$3.91","3.18","70","","","Percent of Total Billed Charges","neg_dollar:$3.18","","52","","4.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.67;102% of Medicaid interim rate","3.41","75","","","Percent of Total Billed Charges","neg_dollar:$3.41","3.91","86","","","Percent of Total Billed Charges","neg_dollar:$3.91","3.18","70","","","Percent of Total Billed Charges","neg_dollar:$3.18","2.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.59;103.5% of Medicaid interim rate","4.55","150","","","Percent of Total Billed Charges","neg_dollar:$7.04;150% of Medicaid interim rate","3.64","80","","","Percent of Total Billed Charges","neg_dollar:$3.64;Percent of Total Billed Charges","4.19","92","","","Percent of Total Billed Charges","neg_dollar:$4.19","2.36","52","","","Percent of Total Billed Charges","neg_dollar:$2.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.55","Fee Schedule","","2.00","4.00",""
"MEMANTINE HCL 5 MG PO TABS","A9270","HCPCS","60687-173-11","NDC","250","RC","","Facility","Outpatient","5","ME","1.18","1.18","","","","1.18","Fee Schedule","","","","","1.18","Fee Schedule","","","","","1.18","Fee Schedule","","","52","","1.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","86","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","70","","","Percent of Total Billed Charges","neg_dollar:$0.82","","52","","1.18","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% of Medicaid interim rate","0.88","75","","","Percent of Total Billed Charges","neg_dollar:$0.88","1.01","86","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","70","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;103.5% of Medicaid interim rate","1.18","150","","","Percent of Total Billed Charges","neg_dollar:$1.83;150% of Medicaid interim rate","0.94","80","","","Percent of Total Billed Charges","neg_dollar:$0.94;Percent of Total Billed Charges","1.09","92","","","Percent of Total Billed Charges","neg_dollar:$1.09","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.18","Fee Schedule","","1.00","1.00",""
"OXYCODONE HCL 5 MG PO TABS","A9270","HCPCS","68084-354-01","NDC","250","RC","","Facility","Outpatient","5","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.55","Fee Schedule","","1.00","1.00",""
"LIDOCAINE 5 % EX PTCH","A9270","HCPCS","82347-0505-4","NDC","250","RC","","Facility","Outpatient","1","EA","4.41","4.41","","","","4.41","Fee Schedule","","","","","4.41","Fee Schedule","","","","","4.41","Fee Schedule","","","52","","4.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.29","52","","","Percent of Total Billed Charges","neg_dollar:$2.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.29","52","","","Percent of Total Billed Charges","neg_dollar:$2.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.80","86","","","Percent of Total Billed Charges","neg_dollar:$3.80","3.09","70","","","Percent of Total Billed Charges","neg_dollar:$3.09","","52","","4.41","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.59;102% of Medicaid interim rate","3.31","75","","","Percent of Total Billed Charges","neg_dollar:$3.31","3.80","86","","","Percent of Total Billed Charges","neg_dollar:$3.80","3.09","70","","","Percent of Total Billed Charges","neg_dollar:$3.09","2.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.51;103.5% of Medicaid interim rate","4.41","150","","","Percent of Total Billed Charges","neg_dollar:$6.83;150% of Medicaid interim rate","3.53","80","","","Percent of Total Billed Charges","neg_dollar:$3.53;Percent of Total Billed Charges","4.06","92","","","Percent of Total Billed Charges","neg_dollar:$4.06","2.29","52","","","Percent of Total Billed Charges","neg_dollar:$2.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.41","Fee Schedule","","2.00","4.00",""
"AMILORIDE HCL 5 MG PO TABS","A9270","HCPCS","00574-0292-01","NDC","637","RC","","Facility","Outpatient","5","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ERYTHROMYCIN 5 MG/GM OP OINT","A9270","HCPCS","24208-910-55","NDC","250","RC","","Facility","Outpatient","1","EA","27.25","27.25","","","","27.25","Fee Schedule","","","","","27.25","Fee Schedule","","","","","27.25","Fee Schedule","","","52","","27.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.43","86","","","Percent of Total Billed Charges","neg_dollar:$23.43","19.07","70","","","Percent of Total Billed Charges","neg_dollar:$19.07","","52","","27.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$16;102% of Medicaid interim rate","20.43","75","","","Percent of Total Billed Charges","neg_dollar:$20.43","23.43","86","","","Percent of Total Billed Charges","neg_dollar:$23.43","19.07","70","","","Percent of Total Billed Charges","neg_dollar:$19.07","15.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.53;103.5% of Medicaid interim rate","27.25","150","","","Percent of Total Billed Charges","neg_dollar:$42.12;150% of Medicaid interim rate","21.80","80","","","Percent of Total Billed Charges","neg_dollar:$21.80;Percent of Total Billed Charges","25.07","92","","","Percent of Total Billed Charges","neg_dollar:$25.07","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","27.25","Fee Schedule","","14.00","27.00",""
"TERAZOSIN HCL 5 MG PO CAPS","A9270","HCPCS","50268-766-11","NDC","250","RC","","Facility","Outpatient","5","ME","1.56","1.56","","","","1.56","Fee Schedule","","","","","1.56","Fee Schedule","","","","","1.56","Fee Schedule","","","52","","1.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","52","","","Percent of Total Billed Charges","neg_dollar:$0.81;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","52","","","Percent of Total Billed Charges","neg_dollar:$0.81;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.34","86","","","Percent of Total Billed Charges","neg_dollar:$1.34","1.09","70","","","Percent of Total Billed Charges","neg_dollar:$1.09","","52","","1.56","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.92;102% of Medicaid interim rate","1.17","75","","","Percent of Total Billed Charges","neg_dollar:$1.17","1.34","86","","","Percent of Total Billed Charges","neg_dollar:$1.34","1.09","70","","","Percent of Total Billed Charges","neg_dollar:$1.09","0.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.89;103.5% of Medicaid interim rate","1.56","150","","","Percent of Total Billed Charges","neg_dollar:$2.42;150% of Medicaid interim rate","1.25","80","","","Percent of Total Billed Charges","neg_dollar:$1.25;Percent of Total Billed Charges","1.44","92","","","Percent of Total Billed Charges","neg_dollar:$1.44","0.81","52","","","Percent of Total Billed Charges","neg_dollar:$0.81;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.56","Fee Schedule","","1.00","1.00",""
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","A9270","HCPCS","60687-814-11","NDC","250","RC","","Facility","Outpatient","5","ME","2.55","2.55","","","","2.55","Fee Schedule","","","","","2.55","Fee Schedule","","","","","2.55","Fee Schedule","","","52","","2.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","52","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","52","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.19","86","","","Percent of Total Billed Charges","neg_dollar:$2.19","1.78","70","","","Percent of Total Billed Charges","neg_dollar:$1.78","","52","","2.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.49;102% of Medicaid interim rate","1.91","75","","","Percent of Total Billed Charges","neg_dollar:$1.91","2.19","86","","","Percent of Total Billed Charges","neg_dollar:$2.19","1.78","70","","","Percent of Total Billed Charges","neg_dollar:$1.78","1.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.45;103.5% of Medicaid interim rate","2.55","150","","","Percent of Total Billed Charges","neg_dollar:$3.94;150% of Medicaid interim rate","2.04","80","","","Percent of Total Billed Charges","neg_dollar:$2.04;Percent of Total Billed Charges","2.34","92","","","Percent of Total Billed Charges","neg_dollar:$2.34","1.32","52","","","Percent of Total Billed Charges","neg_dollar:$1.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.55","Fee Schedule","","1.00","2.00",""
"LIDOCAINE 5 % EX PTCH","A9270","HCPCS","65162-791-08","NDC","250","RC","","Facility","Outpatient","1","EA","4.05","4.05","","","","4.05","Fee Schedule","","","","","4.05","Fee Schedule","","","","","4.05","Fee Schedule","","","52","","4.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.48","86","","","Percent of Total Billed Charges","neg_dollar:$3.48","2.83","70","","","Percent of Total Billed Charges","neg_dollar:$2.83","","52","","4.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.37;102% of Medicaid interim rate","3.03","75","","","Percent of Total Billed Charges","neg_dollar:$3.03","3.48","86","","","Percent of Total Billed Charges","neg_dollar:$3.48","2.83","70","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.30;103.5% of Medicaid interim rate","4.05","150","","","Percent of Total Billed Charges","neg_dollar:$6.26;150% of Medicaid interim rate","3.24","80","","","Percent of Total Billed Charges","neg_dollar:$3.24;Percent of Total Billed Charges","3.72","92","","","Percent of Total Billed Charges","neg_dollar:$3.72","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.05","Fee Schedule","","2.00","4.00",""
"LISINOPRIL 5 MG PO TABS","A9270","HCPCS","60687-667-11","NDC","250","RC","","Facility","Outpatient","5","ME","0.93","0.93","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","52","","0.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","","52","","0.93","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.70","75","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;103.5% of Medicaid interim rate","0.93","150","","","Percent of Total Billed Charges","neg_dollar:$1.44;150% of Medicaid interim rate","0.74","80","","","Percent of Total Billed Charges","neg_dollar:$0.74;Percent of Total Billed Charges","0.86","92","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.93","Fee Schedule","","1.00","1.00",""
"OXYBUTYNIN CHLORIDE 5 MG PO TABS","A9270","HCPCS","60687-670-11","NDC","250","RC","","Facility","Outpatient","5","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.55","Fee Schedule","","1.00","1.00",""
"APIXABAN 5 MG PO TABS","A9270","HCPCS","00003-0894-21","NDC","637","RC","","Facility","Outpatient","5","ME","11.31","11.31","","","","11.31","Fee Schedule","","","","","11.31","Fee Schedule","101% of Medicare Fee Schedule","","","","11.31","Fee Schedule","","5.88","52","","","Percent of Total Billed Charges","neg_dollar:$5.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.31","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.31","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.73","86","","","Percent of Total Billed Charges","neg_dollar:$9.73","7.92","70","","","Percent of Total Billed Charges","neg_dollar:$7.92","5.88","52","","","Percent of Total Billed Charges","neg_dollar:$5.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.64;102% of Medicaid interim rate","8.48","75","","","Percent of Total Billed Charges","neg_dollar:$8.48","9.73","86","","","Percent of Total Billed Charges","neg_dollar:$9.73","7.92","70","","","Percent of Total Billed Charges","neg_dollar:$7.92","6.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.45;103.5% of Medicaid interim rate","11.31","150","","","Percent of Total Billed Charges","neg_dollar:$17.49;150% of Medicaid interim rate","9.05","80","","","Percent of Total Billed Charges","neg_dollar:$9.05;Percent of Total Billed Charges","10.41","92","","","Percent of Total Billed Charges","neg_dollar:$10.41","5.88","52","","","Percent of Total Billed Charges","neg_dollar:$5.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.88","52","","","Percent of Total Billed Charges","neg_dollar:$5.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","11.00",""
"AMLODIPINE BESYLATE 5 MG PO TABS","A9270","HCPCS","00904-6370-61","NDC","637","RC","","Facility","Outpatient","5","ME","0.77","0.77","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","101% of Medicare Fee Schedule","","","","0.77","Fee Schedule","","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.57","75","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.77","150","","","Percent of Total Billed Charges","neg_dollar:$1.19;150% of Medicaid interim rate","0.61","80","","","Percent of Total Billed Charges","neg_dollar:$0.61;Percent of Total Billed Charges","0.71","92","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BISOPROLOL FUMARATE 5 MG PO TABS","A9270","HCPCS","60687-679-11","NDC","250","RC","","Facility","Outpatient","5","ME","2.60","2.60","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","52","","2.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","","52","","2.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.52;102% of Medicaid interim rate","1.95","75","","","Percent of Total Billed Charges","neg_dollar:$1.95","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","1.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.48;103.5% of Medicaid interim rate","2.60","150","","","Percent of Total Billed Charges","neg_dollar:$4.01;150% of Medicaid interim rate","2.08","80","","","Percent of Total Billed Charges","neg_dollar:$2.08;Percent of Total Billed Charges","2.39","92","","","Percent of Total Billed Charges","neg_dollar:$2.39","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.60","Fee Schedule","","1.00","2.00",""
"ERYTHROMYCIN 5 MG/GM OP OINT","A9270","HCPCS","24208-910-55","NDC","637","RC","","Facility","Outpatient","1","UN","27.25","27.25","","","","27.25","Fee Schedule","","","","","27.25","Fee Schedule","101% of Medicare Fee Schedule","","","","27.25","Fee Schedule","","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","27.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","27.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","23.43","86","","","Percent of Total Billed Charges","neg_dollar:$23.43","19.07","70","","","Percent of Total Billed Charges","neg_dollar:$19.07","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$16;102% of Medicaid interim rate","20.43","75","","","Percent of Total Billed Charges","neg_dollar:$20.43","23.43","86","","","Percent of Total Billed Charges","neg_dollar:$23.43","19.07","70","","","Percent of Total Billed Charges","neg_dollar:$19.07","15.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.53;103.5% of Medicaid interim rate","27.25","150","","","Percent of Total Billed Charges","neg_dollar:$42.12;150% of Medicaid interim rate","21.80","80","","","Percent of Total Billed Charges","neg_dollar:$21.80;Percent of Total Billed Charges","25.07","92","","","Percent of Total Billed Charges","neg_dollar:$25.07","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.00","27.00",""
"ZOLPIDEM TARTRATE 5 MG PO TABS","A9270","HCPCS","00904-6082-61","NDC","250","RC","","Facility","Outpatient","5","ME","1.06","1.06","","","","1.06","Fee Schedule","","","","","1.06","Fee Schedule","","","","","1.06","Fee Schedule","","","52","","1.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","86","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.74","70","","","Percent of Total Billed Charges","neg_dollar:$0.74","","52","","1.06","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% of Medicaid interim rate","0.79","75","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.91","86","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.74","70","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;103.5% of Medicaid interim rate","1.06","150","","","Percent of Total Billed Charges","neg_dollar:$1.64;150% of Medicaid interim rate","0.85","80","","","Percent of Total Billed Charges","neg_dollar:$0.85;Percent of Total Billed Charges","0.97","92","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.06","Fee Schedule","","1.00","1.00",""
"AMLODIPINE BESYLATE 5 MG PO TABS","A9270","HCPCS","00904-6370-61","NDC","250","RC","","Facility","Outpatient","5","ME","0.68","0.68","","","","0.68","Fee Schedule","","","","","0.68","Fee Schedule","","","","","0.68","Fee Schedule","","","52","","0.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","86","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.47","70","","","Percent of Total Billed Charges","neg_dollar:$0.47","","52","","0.68","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% of Medicaid interim rate","0.51","75","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.58","86","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.47","70","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.39;103.5% of Medicaid interim rate","0.68","150","","","Percent of Total Billed Charges","neg_dollar:$1.05;150% of Medicaid interim rate","0.54","80","","","Percent of Total Billed Charges","neg_dollar:$0.54;Percent of Total Billed Charges","0.63","92","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.68","Fee Schedule","","1.00","1.00",""
"BUSPIRONE HCL 5 MG PO TABS","A9270","HCPCS","51079-985-01","NDC","250","RC","","Facility","Outpatient","5","ME","0.95","0.95","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","","52","","0.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.71","75","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;103.5% of Medicaid interim rate","0.95","150","","","Percent of Total Billed Charges","neg_dollar:$1.47;150% of Medicaid interim rate","0.76","80","","","Percent of Total Billed Charges","neg_dollar:$0.76;Percent of Total Billed Charges","0.87","92","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.95","Fee Schedule","","1.00","1.00",""
"LIDOCAINE 5 % EX PTCH","A9270","HCPCS","65162-791-04","NDC","250","RC","","Facility","Outpatient","1","EA","4.05","4.05","","","","4.05","Fee Schedule","","","","","4.05","Fee Schedule","","","","","4.05","Fee Schedule","","","52","","4.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.48","86","","","Percent of Total Billed Charges","neg_dollar:$3.48","2.83","70","","","Percent of Total Billed Charges","neg_dollar:$2.83","","52","","4.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.37;102% of Medicaid interim rate","3.03","75","","","Percent of Total Billed Charges","neg_dollar:$3.03","3.48","86","","","Percent of Total Billed Charges","neg_dollar:$3.48","2.83","70","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.30;103.5% of Medicaid interim rate","4.05","150","","","Percent of Total Billed Charges","neg_dollar:$6.26;150% of Medicaid interim rate","3.24","80","","","Percent of Total Billed Charges","neg_dollar:$3.24;Percent of Total Billed Charges","3.72","92","","","Percent of Total Billed Charges","neg_dollar:$3.72","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.05","Fee Schedule","","2.00","4.00",""
"LIDOCAINE 5 % EX PTCH","A9270","HCPCS","00603-1880-16","NDC","637","RC","","Facility","Outpatient","1","EA","4.60","4.60","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","101% of Medicare Fee Schedule","","","","4.60","Fee Schedule","","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% of Medicaid interim rate","3.44","75","","","Percent of Total Billed Charges","neg_dollar:$3.44","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.62;103.5% of Medicaid interim rate","4.60","150","","","Percent of Total Billed Charges","neg_dollar:$7.11;150% of Medicaid interim rate","3.67","80","","","Percent of Total Billed Charges","neg_dollar:$3.67;Percent of Total Billed Charges","4.23","92","","","Percent of Total Billed Charges","neg_dollar:$4.23","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"LISINOPRIL 5 MG PO TABS","A9270","HCPCS","00904-6797-61","NDC","637","RC","","Facility","Outpatient","5","ME","0.68","0.68","","","","0.68","Fee Schedule","","","","","0.68","Fee Schedule","101% of Medicare Fee Schedule","","","","0.68","Fee Schedule","","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","86","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","70","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% of Medicaid interim rate","0.51","75","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.59","86","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","70","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.39;103.5% of Medicaid interim rate","0.68","150","","","Percent of Total Billed Charges","neg_dollar:$1.06;150% of Medicaid interim rate","0.54","80","","","Percent of Total Billed Charges","neg_dollar:$0.54;Percent of Total Billed Charges","0.63","92","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"OXYCODONE HCL 5 MG PO TABS","A9270","HCPCS","10702-018-01","NDC","637","RC","","Facility","Outpatient","5","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ENALAPRIL MALEATE 5 MG PO TABS","A9270","HCPCS","43547-546-10","NDC","637","RC","","Facility","Outpatient","5","ME","0.57","0.57","","","","0.57","Fee Schedule","","","","","0.57","Fee Schedule","101% of Medicare Fee Schedule","","","","0.57","Fee Schedule","","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","86","","","Percent of Total Billed Charges","neg_dollar:$0.49","0.40","70","","","Percent of Total Billed Charges","neg_dollar:$0.40","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% of Medicaid interim rate","0.43","75","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.49","86","","","Percent of Total Billed Charges","neg_dollar:$0.49","0.40","70","","","Percent of Total Billed Charges","neg_dollar:$0.40","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;103.5% of Medicaid interim rate","0.57","150","","","Percent of Total Billed Charges","neg_dollar:$0.89;150% of Medicaid interim rate","0.46","80","","","Percent of Total Billed Charges","neg_dollar:$0.46;Percent of Total Billed Charges","0.53","92","","","Percent of Total Billed Charges","neg_dollar:$0.53","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","A9270","HCPCS","50268-684-11","NDC","637","RC","","Facility","Outpatient","5","ME","1.85","1.85","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","101% of Medicare Fee Schedule","","","","1.85","Fee Schedule","","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;103.5% of Medicaid interim rate","1.85","150","","","Percent of Total Billed Charges","neg_dollar:$2.86;150% of Medicaid interim rate","1.48","80","","","Percent of Total Billed Charges","neg_dollar:$1.48;Percent of Total Billed Charges","1.70","92","","","Percent of Total Billed Charges","neg_dollar:$1.70","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DIAZEPAM 5 MG PO TABS","A9270","HCPCS","51079-285-01","NDC","637","RC","","Facility","Outpatient","5","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE 5 % EX PTCH","A9270","HCPCS","65162-791-08","NDC","637","RC","","Facility","Outpatient","1","EA","4.05","4.05","","","","4.05","Fee Schedule","","","","","4.05","Fee Schedule","101% of Medicare Fee Schedule","","","","4.05","Fee Schedule","","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.48","86","","","Percent of Total Billed Charges","neg_dollar:$3.48","2.83","70","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.37;102% of Medicaid interim rate","3.03","75","","","Percent of Total Billed Charges","neg_dollar:$3.03","3.48","86","","","Percent of Total Billed Charges","neg_dollar:$3.48","2.83","70","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.30;103.5% of Medicaid interim rate","4.05","150","","","Percent of Total Billed Charges","neg_dollar:$6.26;150% of Medicaid interim rate","3.24","80","","","Percent of Total Billed Charges","neg_dollar:$3.24;Percent of Total Billed Charges","3.72","92","","","Percent of Total Billed Charges","neg_dollar:$3.72","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"RAMIPRIL 5 MG PO CAPS","A9270","HCPCS","68382-146-01","NDC","637","RC","","Facility","Outpatient","5","ME","0.77","0.77","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","101% of Medicare Fee Schedule","","","","0.77","Fee Schedule","","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.58","75","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.77","150","","","Percent of Total Billed Charges","neg_dollar:$1.19;150% of Medicaid interim rate","0.62","80","","","Percent of Total Billed Charges","neg_dollar:$0.62;Percent of Total Billed Charges","0.71","92","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BISACODYL 5 MG PO TBEC","A9270","HCPCS","00904-6407-61","NDC","637","RC","","Facility","Outpatient","5","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","101% of Medicare Fee Schedule","","","","1.05","Fee Schedule","","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"OLANZAPINE 5 MG PO TABS","A9270","HCPCS","60505-3111-0","NDC","637","RC","","Facility","Outpatient","5","ME","0.80","0.80","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","101% of Medicare Fee Schedule","","","","0.80","Fee Schedule","","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.60","75","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.80","150","","","Percent of Total Billed Charges","neg_dollar:$1.23;150% of Medicaid interim rate","0.64","80","","","Percent of Total Billed Charges","neg_dollar:$0.64;Percent of Total Billed Charges","0.73","92","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MEMANTINE HCL 5 MG PO TABS","A9270","HCPCS","60687-173-11","NDC","637","RC","","Facility","Outpatient","5","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"OXYCODONE HCL 5 MG PO TABS","A9270","HCPCS","68084-354-01","NDC","637","RC","","Facility","Outpatient","5","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","101% of Medicare Fee Schedule","","","","1.55","Fee Schedule","","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"WARFARIN SODIUM 5 MG PO TABS","A9270","HCPCS","00832-1216-89","NDC","637","RC","","Facility","Outpatient","5","ME","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","101% of Medicare Fee Schedule","","","","1.50","Fee Schedule","","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.31;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TERAZOSIN HCL 5 MG PO CAPS","A9270","HCPCS","50268-766-11","NDC","637","RC","","Facility","Outpatient","5","ME","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","101% of Medicare Fee Schedule","","","","2.05","Fee Schedule","","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"LISINOPRIL 5 MG PO TABS","A9270","HCPCS","60687-667-11","NDC","637","RC","","Facility","Outpatient","5","ME","0.98","0.98","","","","0.98","Fee Schedule","","","","","0.98","Fee Schedule","101% of Medicare Fee Schedule","","","","0.98","Fee Schedule","","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.84","86","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.69","70","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% of Medicaid interim rate","0.74","75","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.84","86","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.69","70","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;103.5% of Medicaid interim rate","0.98","150","","","Percent of Total Billed Charges","neg_dollar:$1.52;150% of Medicaid interim rate","0.79","80","","","Percent of Total Billed Charges","neg_dollar:$0.79;Percent of Total Billed Charges","0.90","92","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE 5 % EX PTCH","A9270","HCPCS","00591-3525-11","NDC","637","RC","","Facility","Outpatient","5","EA","4.60","4.60","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","101% of Medicare Fee Schedule","","","","4.60","Fee Schedule","","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% of Medicaid interim rate","3.44","75","","","Percent of Total Billed Charges","neg_dollar:$3.44","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.62;103.5% of Medicaid interim rate","4.60","150","","","Percent of Total Billed Charges","neg_dollar:$7.11;150% of Medicaid interim rate","3.67","80","","","Percent of Total Billed Charges","neg_dollar:$3.67;Percent of Total Billed Charges","4.23","92","","","Percent of Total Billed Charges","neg_dollar:$4.23","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"OXYBUTYNIN CHLORIDE 5 MG PO TABS","A9270","HCPCS","60687-670-11","NDC","637","RC","","Facility","Outpatient","5","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","101% of Medicare Fee Schedule","","","","1.55","Fee Schedule","","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BUSPIRONE HCL 5 MG PO TABS","A9270","HCPCS","51079-985-01","NDC","637","RC","","Facility","Outpatient","5","ME","0.79","0.79","","","","0.79","Fee Schedule","","","","","0.79","Fee Schedule","101% of Medicare Fee Schedule","","","","0.79","Fee Schedule","","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.59","75","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.79","150","","","Percent of Total Billed Charges","neg_dollar:$1.22;150% of Medicaid interim rate","0.63","80","","","Percent of Total Billed Charges","neg_dollar:$0.63;Percent of Total Billed Charges","0.73","92","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE 5 % EX PTCH","A9270","HCPCS","82347-0505-4","NDC","637","RC","","Facility","Outpatient","1","EA","4.45","4.45","","","","4.45","Fee Schedule","","","","","4.45","Fee Schedule","101% of Medicare Fee Schedule","","","","4.45","Fee Schedule","","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.82","86","","","Percent of Total Billed Charges","neg_dollar:$3.82","3.11","70","","","Percent of Total Billed Charges","neg_dollar:$3.11","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.61;102% of Medicaid interim rate","3.33","75","","","Percent of Total Billed Charges","neg_dollar:$3.33","3.82","86","","","Percent of Total Billed Charges","neg_dollar:$3.82","3.11","70","","","Percent of Total Billed Charges","neg_dollar:$3.11","2.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.53;103.5% of Medicaid interim rate","4.45","150","","","Percent of Total Billed Charges","neg_dollar:$6.87;150% of Medicaid interim rate","3.56","80","","","Percent of Total Billed Charges","neg_dollar:$3.56;Percent of Total Billed Charges","4.09","92","","","Percent of Total Billed Charges","neg_dollar:$4.09","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"OXYCODONE HCL 5 MG PO TABS","A9270","HCPCS","68084-354-11","NDC","637","RC","","Facility","Outpatient","5","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.90","75","","","Percent of Total Billed Charges","neg_dollar:$0.90","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.86;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.11","92","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"GLIPIZIDE 5 MG PO TABS","A9270","HCPCS","50268-361-11","NDC","637","RC","","Facility","Outpatient","5","ME","0.99","0.99","","","","0.99","Fee Schedule","","","","","0.99","Fee Schedule","101% of Medicare Fee Schedule","","","","0.99","Fee Schedule","","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.99","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.99","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","86","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","70","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% of Medicaid interim rate","0.74","75","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.85","86","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","70","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;103.5% of Medicaid interim rate","0.99","150","","","Percent of Total Billed Charges","neg_dollar:$1.53;150% of Medicaid interim rate","0.79","80","","","Percent of Total Billed Charges","neg_dollar:$0.79;Percent of Total Billed Charges","0.91","92","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"OXYBUTYNIN CHLORIDE ER 5 MG PO TB24","A9270","HCPCS","50268-627-11","NDC","637","RC","","Facility","Outpatient","5","ME","3.85","3.85","","","","3.85","Fee Schedule","","","","","3.85","Fee Schedule","101% of Medicare Fee Schedule","","","","3.85","Fee Schedule","","2.00","52","","","Percent of Total Billed Charges","neg_dollar:$2;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.31","86","","","Percent of Total Billed Charges","neg_dollar:$3.31","2.69","70","","","Percent of Total Billed Charges","neg_dollar:$2.69","2.00","52","","","Percent of Total Billed Charges","neg_dollar:$2;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.26;102% of Medicaid interim rate","2.88","75","","","Percent of Total Billed Charges","neg_dollar:$2.88","3.31","86","","","Percent of Total Billed Charges","neg_dollar:$3.31","2.69","70","","","Percent of Total Billed Charges","neg_dollar:$2.69","2.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.19;103.5% of Medicaid interim rate","3.85","150","","","Percent of Total Billed Charges","neg_dollar:$5.95;150% of Medicaid interim rate","3.08","80","","","Percent of Total Billed Charges","neg_dollar:$3.08;Percent of Total Billed Charges","3.54","92","","","Percent of Total Billed Charges","neg_dollar:$3.54","2.00","52","","","Percent of Total Billed Charges","neg_dollar:$2;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","52","","","Percent of Total Billed Charges","neg_dollar:$2;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","3.00",""
"OXYCODONE HCL 5 MG PO TABS","A9270","HCPCS","68084-354-11","NDC","250","RC","","Facility","Outpatient","5","ME","1.61","1.61","","","","1.61","Fee Schedule","","","","","1.61","Fee Schedule","","","","","1.61","Fee Schedule","","","52","","1.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.13","70","","","Percent of Total Billed Charges","neg_dollar:$1.13","","52","","1.61","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;102% of Medicaid interim rate","1.21","75","","","Percent of Total Billed Charges","neg_dollar:$1.21","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.13","70","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.92;103.5% of Medicaid interim rate","1.61","150","","","Percent of Total Billed Charges","neg_dollar:$2.49;150% of Medicaid interim rate","1.29","80","","","Percent of Total Billed Charges","neg_dollar:$1.29;Percent of Total Billed Charges","1.48","92","","","Percent of Total Billed Charges","neg_dollar:$1.48","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.61","Fee Schedule","","1.00","1.00",""
"ZOLPIDEM TARTRATE 5 MG PO TABS","A9270","HCPCS","00904-6082-61","NDC","637","RC","","Facility","Outpatient","5","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","101% of Medicare Fee Schedule","","","","1.15","Fee Schedule","","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE 5 % EX PTCH","A9270","HCPCS","65162-791-04","NDC","637","RC","","Facility","Outpatient","1","EA","4.05","4.05","","","","4.05","Fee Schedule","","","","","4.05","Fee Schedule","101% of Medicare Fee Schedule","","","","4.05","Fee Schedule","","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.48","86","","","Percent of Total Billed Charges","neg_dollar:$3.48","2.83","70","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.37;102% of Medicaid interim rate","3.03","75","","","Percent of Total Billed Charges","neg_dollar:$3.03","3.48","86","","","Percent of Total Billed Charges","neg_dollar:$3.48","2.83","70","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.30;103.5% of Medicaid interim rate","4.05","150","","","Percent of Total Billed Charges","neg_dollar:$6.26;150% of Medicaid interim rate","3.24","80","","","Percent of Total Billed Charges","neg_dollar:$3.24;Percent of Total Billed Charges","3.72","92","","","Percent of Total Billed Charges","neg_dollar:$3.72","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"FINASTERIDE 5 MG PO TABS","A9270","HCPCS","60687-428-11","NDC","250","RC","","Facility","Outpatient","5","ME","2.10","2.10","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","","52","","2.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% of Medicaid interim rate","1.57","75","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.19;103.5% of Medicaid interim rate","2.10","150","","","Percent of Total Billed Charges","neg_dollar:$3.24;150% of Medicaid interim rate","1.68","80","","","Percent of Total Billed Charges","neg_dollar:$1.68;Percent of Total Billed Charges","1.93","92","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.10","Fee Schedule","","1.00","2.00",""
"FINASTERIDE 5 MG PO TABS","A9270","HCPCS","60687-428-11","NDC","637","RC","","Facility","Outpatient","5","ME","2.10","2.10","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","101% of Medicare Fee Schedule","","","","2.10","Fee Schedule","","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% of Medicaid interim rate","1.57","75","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.19;103.5% of Medicaid interim rate","2.10","150","","","Percent of Total Billed Charges","neg_dollar:$3.24;150% of Medicaid interim rate","1.68","80","","","Percent of Total Billed Charges","neg_dollar:$1.68;Percent of Total Billed Charges","1.93","92","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"ATENOLOL 50 MG PO TABS","A9270","HCPCS","51079-684-01","NDC","250","RC","","Facility","Outpatient","50","ME","1.08","1.08","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","","","52","","1.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","","52","","1.08","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.08","150","","","Percent of Total Billed Charges","neg_dollar:$1.68;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.00","92","","","Percent of Total Billed Charges","neg_dollar:$1","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.08","Fee Schedule","","1.00","1.00",""
"FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP","A9270","HCPCS","60505-0829-1","NDC","250","RC","","Facility","Outpatient","1","UN","30.30","30.30","","","","30.30","Fee Schedule","","","","","30.30","Fee Schedule","","","","","30.30","Fee Schedule","","","52","","30.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.75","52","","","Percent of Total Billed Charges","neg_dollar:$15.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.75","52","","","Percent of Total Billed Charges","neg_dollar:$15.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.05","86","","","Percent of Total Billed Charges","neg_dollar:$26.05","21.21","70","","","Percent of Total Billed Charges","neg_dollar:$21.21","","52","","30.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","17.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.80;102% of Medicaid interim rate","22.72","75","","","Percent of Total Billed Charges","neg_dollar:$22.72","26.05","86","","","Percent of Total Billed Charges","neg_dollar:$26.05","21.21","70","","","Percent of Total Billed Charges","neg_dollar:$21.21","17.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.27;103.5% of Medicaid interim rate","30.30","150","","","Percent of Total Billed Charges","neg_dollar:$46.84;150% of Medicaid interim rate","24.24","80","","","Percent of Total Billed Charges","neg_dollar:$24.24;Percent of Total Billed Charges","27.87","92","","","Percent of Total Billed Charges","neg_dollar:$27.87","15.75","52","","","Percent of Total Billed Charges","neg_dollar:$15.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","30.30","Fee Schedule","","15.00","30.00",""
"PREGABALIN 50 MG PO CAPS","A9270","HCPCS","60687-484-01","NDC","250","RC","","Facility","Outpatient","50","ME","2.30","2.30","","","","2.30","Fee Schedule","","","","","2.30","Fee Schedule","","","","","2.30","Fee Schedule","","","52","","2.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.19","52","","","Percent of Total Billed Charges","neg_dollar:$1.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.19","52","","","Percent of Total Billed Charges","neg_dollar:$1.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.97","86","","","Percent of Total Billed Charges","neg_dollar:$1.97","1.60","70","","","Percent of Total Billed Charges","neg_dollar:$1.60","","52","","2.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% of Medicaid interim rate","1.72","75","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.97","86","","","Percent of Total Billed Charges","neg_dollar:$1.97","1.60","70","","","Percent of Total Billed Charges","neg_dollar:$1.60","1.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.31;103.5% of Medicaid interim rate","2.30","150","","","Percent of Total Billed Charges","neg_dollar:$3.55;150% of Medicaid interim rate","1.83","80","","","Percent of Total Billed Charges","neg_dollar:$1.83;Percent of Total Billed Charges","2.11","92","","","Percent of Total Billed Charges","neg_dollar:$2.11","1.19","52","","","Percent of Total Billed Charges","neg_dollar:$1.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.30","Fee Schedule","","1.00","2.00",""
"NITROFURANTOIN MACROCRYSTAL 50 MG PO CAPS","A9270","HCPCS","00115-1643-01","NDC","250","RC","","Facility","Outpatient","50","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"TRAZODONE HCL 50 MG PO TABS","A9270","HCPCS","00904-6868-61","NDC","250","RC","","Facility","Outpatient","50","ME","0.91","0.91","","","","0.91","Fee Schedule","","","","","0.91","Fee Schedule","","","","","0.91","Fee Schedule","","","52","","0.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","","52","","0.91","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% of Medicaid interim rate","0.68","75","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.91","150","","","Percent of Total Billed Charges","neg_dollar:$1.40;150% of Medicaid interim rate","0.72","80","","","Percent of Total Billed Charges","neg_dollar:$0.72;Percent of Total Billed Charges","0.83","92","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.91","Fee Schedule","","1.00","1.00",""
"SITAGLIPTIN PHOSPHATE 50 MG PO TABS","A9270","HCPCS","00006-0112-31","NDC","250","RC","","Facility","Outpatient","50","ME","15.03","15.03","","","","15.03","Fee Schedule","","","","","15.03","Fee Schedule","","","","","15.03","Fee Schedule","","","52","","15.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.81","52","","","Percent of Total Billed Charges","neg_dollar:$7.81;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.81","52","","","Percent of Total Billed Charges","neg_dollar:$7.81;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.92","86","","","Percent of Total Billed Charges","neg_dollar:$12.92","10.52","70","","","Percent of Total Billed Charges","neg_dollar:$10.52","","52","","15.03","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.83;102% of Medicaid interim rate","11.27","75","","","Percent of Total Billed Charges","neg_dollar:$11.27","12.92","86","","","Percent of Total Billed Charges","neg_dollar:$12.92","10.52","70","","","Percent of Total Billed Charges","neg_dollar:$10.52","8.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.56;103.5% of Medicaid interim rate","15.03","150","","","Percent of Total Billed Charges","neg_dollar:$23.24;150% of Medicaid interim rate","12.02","80","","","Percent of Total Billed Charges","neg_dollar:$12.02;Percent of Total Billed Charges","13.83","92","","","Percent of Total Billed Charges","neg_dollar:$13.83","7.81","52","","","Percent of Total Billed Charges","neg_dollar:$7.81;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","15.03","Fee Schedule","","7.00","15.00",""
"LOSARTAN POTASSIUM 50 MG PO TABS","A9270","HCPCS","68084-347-11","NDC","250","RC","","Facility","Outpatient","50","ME","1.63","1.63","","","","1.63","Fee Schedule","","","","","1.63","Fee Schedule","","","","","1.63","Fee Schedule","","","52","","1.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","86","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","70","","","Percent of Total Billed Charges","neg_dollar:$1.14","","52","","1.63","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.22","75","","","Percent of Total Billed Charges","neg_dollar:$1.22","1.40","86","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","70","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;103.5% of Medicaid interim rate","1.63","150","","","Percent of Total Billed Charges","neg_dollar:$2.53;150% of Medicaid interim rate","1.31","80","","","Percent of Total Billed Charges","neg_dollar:$1.31;Percent of Total Billed Charges","1.50","92","","","Percent of Total Billed Charges","neg_dollar:$1.50","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.63","Fee Schedule","","1.00","1.00",""
"SERTRALINE HCL 50 MG PO TABS","A9270","HCPCS","60687-242-11","NDC","250","RC","","Facility","Outpatient","50","ME","0.90","0.90","","","","0.90","Fee Schedule","","","","","0.90","Fee Schedule","","","","","0.90","Fee Schedule","","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","","52","","0.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% of Medicaid interim rate","0.67","75","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.90","150","","","Percent of Total Billed Charges","neg_dollar:$1.39;150% of Medicaid interim rate","0.72","80","","","Percent of Total Billed Charges","neg_dollar:$0.72;Percent of Total Billed Charges","0.82","92","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.90","Fee Schedule","","1.00","1.00",""
"TRAMADOL HCL 50 MG PO TABS","A9270","HCPCS","68084-808-11","NDC","250","RC","","Facility","Outpatient","50","ME","1.11","1.11","","","","1.11","Fee Schedule","","","","","1.11","Fee Schedule","","","","","1.11","Fee Schedule","","","52","","1.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","86","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.11","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% of Medicaid interim rate","0.83","75","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.95","86","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;103.5% of Medicaid interim rate","1.11","150","","","Percent of Total Billed Charges","neg_dollar:$1.71;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.02","92","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.11","Fee Schedule","","1.00","1.00",""
"TRAMADOL HCL 50 MG PO TABS","A9270","HCPCS","60687-795-11","NDC","250","RC","","Facility","Outpatient","50","ME","0.93","0.93","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","52","","0.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","","52","","0.93","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.70","75","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;103.5% of Medicaid interim rate","0.93","150","","","Percent of Total Billed Charges","neg_dollar:$1.44;150% of Medicaid interim rate","0.75","80","","","Percent of Total Billed Charges","neg_dollar:$0.75;Percent of Total Billed Charges","0.86","92","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.93","Fee Schedule","","1.00","1.00",""
"PREGABALIN 50 MG PO CAPS","A9270","HCPCS","60687-484-11","NDC","250","RC","","Facility","Outpatient","50","ME","18.57","18.57","","","","18.57","Fee Schedule","","","","","18.57","Fee Schedule","","","","","18.57","Fee Schedule","","","52","","18.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.65","52","","","Percent of Total Billed Charges","neg_dollar:$9.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.65","52","","","Percent of Total Billed Charges","neg_dollar:$9.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.97","86","","","Percent of Total Billed Charges","neg_dollar:$15.97","13.00","70","","","Percent of Total Billed Charges","neg_dollar:$13","","52","","18.57","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.91;102% of Medicaid interim rate","13.93","75","","","Percent of Total Billed Charges","neg_dollar:$13.93","15.97","86","","","Percent of Total Billed Charges","neg_dollar:$15.97","13.00","70","","","Percent of Total Billed Charges","neg_dollar:$13","10.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.58;103.5% of Medicaid interim rate","18.57","150","","","Percent of Total Billed Charges","neg_dollar:$28.71;150% of Medicaid interim rate","14.86","80","","","Percent of Total Billed Charges","neg_dollar:$14.86;Percent of Total Billed Charges","17.08","92","","","Percent of Total Billed Charges","neg_dollar:$17.08","9.65","52","","","Percent of Total Billed Charges","neg_dollar:$9.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","18.57","Fee Schedule","","9.00","18.00",""
"FLECAINIDE ACETATE 50 MG PO TABS","A9270","HCPCS","00054-0010-20","NDC","637","RC","","Facility","Outpatient","50","ME","1.36","1.36","","","","1.36","Fee Schedule","","","","","1.36","Fee Schedule","101% of Medicare Fee Schedule","","","","1.36","Fee Schedule","","0.71","52","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","86","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.95","70","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.71","52","","","Percent of Total Billed Charges","neg_dollar:$0.71;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% of Medicaid interim rate","1.02","75","","","Percent of Total Billed Charges","neg_dollar:$1.02","1.17","86","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.95","70","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.77;103.5% of Medicaid interim rate","1.36","150","","","Percent of Total Billed Charges","neg_dollar:$2.11;150% of Medicaid interim rate","1.09","80","","","Percent of Total Billed Charges","neg_dollar:$1.09;Percent of Total Billed Charges","1.25","92","","","Percent of Total Billed Charges","neg_dollar:$1.25","0.71","52","","","Percent of Total Billed Charges","neg_dollar:$0.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","52","","","Percent of Total Billed Charges","neg_dollar:$0.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SUMATRIPTAN SUCCINATE 50 MG PO TABS","A9270","HCPCS","16714-797-01","NDC","637","RC","","Facility","Outpatient","50","ME","3.15","3.15","","","","3.15","Fee Schedule","","","","","3.15","Fee Schedule","101% of Medicare Fee Schedule","","","","3.15","Fee Schedule","","1.63","52","","","Percent of Total Billed Charges","neg_dollar:$1.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","86","","","Percent of Total Billed Charges","neg_dollar:$2.70","2.20","70","","","Percent of Total Billed Charges","neg_dollar:$2.20","1.63","52","","","Percent of Total Billed Charges","neg_dollar:$1.63;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.85;102% of Medicaid interim rate","2.36","75","","","Percent of Total Billed Charges","neg_dollar:$2.36","2.70","86","","","Percent of Total Billed Charges","neg_dollar:$2.70","2.20","70","","","Percent of Total Billed Charges","neg_dollar:$2.20","1.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.79;103.5% of Medicaid interim rate","3.15","150","","","Percent of Total Billed Charges","neg_dollar:$4.87;150% of Medicaid interim rate","2.52","80","","","Percent of Total Billed Charges","neg_dollar:$2.52;Percent of Total Billed Charges","2.89","92","","","Percent of Total Billed Charges","neg_dollar:$2.89","1.63","52","","","Percent of Total Billed Charges","neg_dollar:$1.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.63","52","","","Percent of Total Billed Charges","neg_dollar:$1.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"LEVOTHYROXINE SODIUM 50 MCG PO TABS","A9270","HCPCS","51079-440-01","NDC","250","RC","","Facility","Outpatient","50","EA","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"SITAGLIPTIN PHOSPHATE 50 MG PO TABS","A9270","HCPCS","00006-0112-31","NDC","637","RC","","Facility","Outpatient","50","ME","16.57","16.57","","","","16.57","Fee Schedule","","","","","16.57","Fee Schedule","101% of Medicare Fee Schedule","","","","16.57","Fee Schedule","","8.61","52","","","Percent of Total Billed Charges","neg_dollar:$8.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.25","86","","","Percent of Total Billed Charges","neg_dollar:$14.25","11.60","70","","","Percent of Total Billed Charges","neg_dollar:$11.60","8.61","52","","","Percent of Total Billed Charges","neg_dollar:$8.61;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.73;102% of Medicaid interim rate","12.42","75","","","Percent of Total Billed Charges","neg_dollar:$12.42","14.25","86","","","Percent of Total Billed Charges","neg_dollar:$14.25","11.60","70","","","Percent of Total Billed Charges","neg_dollar:$11.60","9.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.44;103.5% of Medicaid interim rate","16.57","150","","","Percent of Total Billed Charges","neg_dollar:$25.62;150% of Medicaid interim rate","13.25","80","","","Percent of Total Billed Charges","neg_dollar:$13.25;Percent of Total Billed Charges","15.24","92","","","Percent of Total Billed Charges","neg_dollar:$15.24","8.61","52","","","Percent of Total Billed Charges","neg_dollar:$8.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.61","52","","","Percent of Total Billed Charges","neg_dollar:$8.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","16.00",""
"PRIMIDONE 50 MG PO TABS","A9270","HCPCS","68084-202-11","NDC","250","RC","","Facility","Outpatient","50","ME","2","2.00","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","","52","","2.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.00","Fee Schedule","","1.00","2.00",""
"LEVOTHYROXINE SODIUM 50 MCG PO TABS","A9270","HCPCS","60687-464-11","NDC","250","RC","","Facility","Outpatient","50","EA","1.53","1.53","","","","1.53","Fee Schedule","","","","","1.53","Fee Schedule","","","","","1.53","Fee Schedule","","","52","","1.53","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","86","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.07","70","","","Percent of Total Billed Charges","neg_dollar:$1.07","","52","","1.53","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.90;102% of Medicaid interim rate","1.15","75","","","Percent of Total Billed Charges","neg_dollar:$1.15","1.32","86","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.07","70","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.87;103.5% of Medicaid interim rate","1.53","150","","","Percent of Total Billed Charges","neg_dollar:$2.37;150% of Medicaid interim rate","1.23","80","","","Percent of Total Billed Charges","neg_dollar:$1.23;Percent of Total Billed Charges","1.41","92","","","Percent of Total Billed Charges","neg_dollar:$1.41","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.53","Fee Schedule","","1.00","1.00",""
"SUMATRIPTAN SUCCINATE 50 MG PO TABS","A9270","HCPCS","65862-147-36","NDC","250","RC","","Facility","Outpatient","50","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.55","Fee Schedule","","1.00","1.00",""
"LOSARTAN POTASSIUM 50 MG PO TABS","A9270","HCPCS","68084-347-01","NDC","250","RC","","Facility","Outpatient","50","ME","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","","52","","1.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.75","Fee Schedule","","1.00","1.00",""
"TRAMADOL HCL 50 MG PO TABS","A9270","HCPCS","68084-808-11","NDC","637","RC","","Facility","Outpatient","50","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LOSARTAN POTASSIUM 50 MG PO TABS","A9270","HCPCS","68084-347-11","NDC","637","RC","","Facility","Outpatient","50","ME","1.51","1.51","","","","1.51","Fee Schedule","","","","","1.51","Fee Schedule","101% of Medicare Fee Schedule","","","","1.51","Fee Schedule","","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","86","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.06","70","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.89;102% of Medicaid interim rate","1.13","75","","","Percent of Total Billed Charges","neg_dollar:$1.13","1.30","86","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.06","70","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.86;103.5% of Medicaid interim rate","1.51","150","","","Percent of Total Billed Charges","neg_dollar:$2.34;150% of Medicaid interim rate","1.21","80","","","Percent of Total Billed Charges","neg_dollar:$1.21;Percent of Total Billed Charges","1.39","92","","","Percent of Total Billed Charges","neg_dollar:$1.39","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TRAZODONE HCL 50 MG PO TABS","A9270","HCPCS","00904-6868-61","NDC","637","RC","","Facility","Outpatient","50","ME","0.88","0.88","","","","0.88","Fee Schedule","","","","","0.88","Fee Schedule","101% of Medicare Fee Schedule","","","","0.88","Fee Schedule","","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","86","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","70","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% of Medicaid interim rate","0.66","75","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.76","86","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","70","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.50;103.5% of Medicaid interim rate","0.88","150","","","Percent of Total Billed Charges","neg_dollar:$1.37;150% of Medicaid interim rate","0.71","80","","","Percent of Total Billed Charges","neg_dollar:$0.71;Percent of Total Billed Charges","0.81","92","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SERTRALINE HCL 50 MG PO TABS","A9270","HCPCS","60687-242-11","NDC","637","RC","","Facility","Outpatient","50","ME","1.03","1.03","","","","1.03","Fee Schedule","","","","","1.03","Fee Schedule","101% of Medicare Fee Schedule","","","","1.03","Fee Schedule","","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% of Medicaid interim rate","0.77","75","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.03","150","","","Percent of Total Billed Charges","neg_dollar:$1.60;150% of Medicaid interim rate","0.82","80","","","Percent of Total Billed Charges","neg_dollar:$0.82;Percent of Total Billed Charges","0.95","92","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TRAMADOL HCL 50 MG PO TABS","A9270","HCPCS","60687-795-11","NDC","637","RC","","Facility","Outpatient","50","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PRIMIDONE 50 MG PO TABS","A9270","HCPCS","68084-202-11","NDC","637","RC","","Facility","Outpatient","50","ME","2","2.00","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"TRAMADOL HCL 50 MG PO TABS","A9270","HCPCS","68084-808-01","NDC","637","RC","","Facility","Outpatient","50","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ATENOLOL 50 MG PO TABS","A9270","HCPCS","51079-684-01","NDC","637","RC","","Facility","Outpatient","50","ME","1.08","1.08","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","101% of Medicare Fee Schedule","","","","1.08","Fee Schedule","","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;103.5% of Medicaid interim rate","1.08","150","","","Percent of Total Billed Charges","neg_dollar:$1.66;150% of Medicaid interim rate","0.86","80","","","Percent of Total Billed Charges","neg_dollar:$0.86;Percent of Total Billed Charges","0.99","92","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP","A9270","HCPCS","60505-0829-1","NDC","637","RC","","Facility","Outpatient","1","UN","30.30","30.30","","","","30.30","Fee Schedule","","","","","30.30","Fee Schedule","101% of Medicare Fee Schedule","","","","30.30","Fee Schedule","","15.75","52","","","Percent of Total Billed Charges","neg_dollar:$15.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","30.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","30.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","26.05","86","","","Percent of Total Billed Charges","neg_dollar:$26.05","21.21","70","","","Percent of Total Billed Charges","neg_dollar:$21.21","15.75","52","","","Percent of Total Billed Charges","neg_dollar:$15.75;105% Medicare Outpatient Cost to Charge Ratio of 52%","17.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.80;102% of Medicaid interim rate","22.72","75","","","Percent of Total Billed Charges","neg_dollar:$22.72","26.05","86","","","Percent of Total Billed Charges","neg_dollar:$26.05","21.21","70","","","Percent of Total Billed Charges","neg_dollar:$21.21","17.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.27;103.5% of Medicaid interim rate","30.30","150","","","Percent of Total Billed Charges","neg_dollar:$46.84;150% of Medicaid interim rate","24.24","80","","","Percent of Total Billed Charges","neg_dollar:$24.24;Percent of Total Billed Charges","27.87","92","","","Percent of Total Billed Charges","neg_dollar:$27.87","15.75","52","","","Percent of Total Billed Charges","neg_dollar:$15.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.75","52","","","Percent of Total Billed Charges","neg_dollar:$15.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.00","30.00",""
"PREGABALIN 50 MG PO CAPS","A9270","HCPCS","60687-484-11","NDC","637","RC","","Facility","Outpatient","50","ME","1.91","1.91","","","","1.91","Fee Schedule","","","","","1.91","Fee Schedule","101% of Medicare Fee Schedule","","","","1.91","Fee Schedule","","0.99","52","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.64","86","","","Percent of Total Billed Charges","neg_dollar:$1.64","1.34","70","","","Percent of Total Billed Charges","neg_dollar:$1.34","0.99","52","","","Percent of Total Billed Charges","neg_dollar:$0.99;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.12;102% of Medicaid interim rate","1.43","75","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.64","86","","","Percent of Total Billed Charges","neg_dollar:$1.64","1.34","70","","","Percent of Total Billed Charges","neg_dollar:$1.34","1.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.09;103.5% of Medicaid interim rate","1.91","150","","","Percent of Total Billed Charges","neg_dollar:$2.96;150% of Medicaid interim rate","1.53","80","","","Percent of Total Billed Charges","neg_dollar:$1.53;Percent of Total Billed Charges","1.76","92","","","Percent of Total Billed Charges","neg_dollar:$1.76","0.99","52","","","Percent of Total Billed Charges","neg_dollar:$0.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","52","","","Percent of Total Billed Charges","neg_dollar:$0.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TRAMADOL HCL 50 MG PO TABS","A9270","HCPCS","68084-808-01","NDC","250","RC","","Facility","Outpatient","50","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"LEVOTHYROXINE SODIUM 50 MCG PO TABS","A9270","HCPCS","51079-440-01","NDC","637","RC","","Facility","Outpatient","50","EA","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","101% of Medicare Fee Schedule","","","","1.60","Fee Schedule","","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TAKE HOME TRAMADOL 50 MG PO TABS (QTY:SIX)","A9270","HCPCS","68084-808-01","NDC","253","RC","","Facility","Outpatient","50","ME","11","11.00","11.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","11.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.45","86","","","Percent of Total Billed Charges","neg_dollar:$9.45","7.69","70","","","Percent of Total Billed Charges","neg_dollar:$7.69","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.46;102% of Medicaid interim rate","8.25","75","","","Percent of Total Billed Charges","neg_dollar:$8.25","9.45","86","","","Percent of Total Billed Charges","neg_dollar:$9.45","7.69","70","","","Percent of Total Billed Charges","neg_dollar:$7.69","6.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.27;103.5% of Medicaid interim rate","11.00","150","","","Percent of Total Billed Charges","neg_dollar:$17;150% of Medicaid interim rate","8.80","80","","","Percent of Total Billed Charges","neg_dollar:$8.80;Percent of Total Billed Charges","10.12","92","","","Percent of Total Billed Charges","neg_dollar:$10.12","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.72","52","","","Percent of Total Billed Charges","neg_dollar:$5.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","11.00",""
"METRONIDAZOLE 500 MG PO TABS","A9270","HCPCS","00904-7126-61","NDC","250","RC","","Facility","Outpatient","500","ME","1.85","1.85","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","","52","","1.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;103.5% of Medicaid interim rate","1.85","150","","","Percent of Total Billed Charges","neg_dollar:$2.86;150% of Medicaid interim rate","1.48","80","","","Percent of Total Billed Charges","neg_dollar:$1.48;Percent of Total Billed Charges","1.70","92","","","Percent of Total Billed Charges","neg_dollar:$1.70","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.85","Fee Schedule","","1.00","1.00",""
"CIPROFLOXACIN HCL 500 MG PO TABS","A9270","HCPCS","00904-7083-61","NDC","250","RC","","Facility","Outpatient","500","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"METFORMIN HCL ER 500 MG PO TB24","A9270","HCPCS","50268-550-11","NDC","250","RC","","Facility","Outpatient","500","ME","1.14","1.14","","","","1.14","Fee Schedule","","","","","1.14","Fee Schedule","","","","","1.14","Fee Schedule","","","52","","1.14","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.79","70","","","Percent of Total Billed Charges","neg_dollar:$0.79","","52","","1.14","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.85","75","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.79","70","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.14","150","","","Percent of Total Billed Charges","neg_dollar:$1.76;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.14","Fee Schedule","","1.00","1.00",""
"LEVETIRACETAM 500 MG PO TABS","A9270","HCPCS","51079-821-01","NDC","250","RC","","Facility","Outpatient","500","ME","1.22","1.22","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","","","52","","1.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","","52","","1.22","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% of Medicaid interim rate","0.91","75","","","Percent of Total Billed Charges","neg_dollar:$0.91","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;103.5% of Medicaid interim rate","1.22","150","","","Percent of Total Billed Charges","neg_dollar:$1.89;150% of Medicaid interim rate","0.97","80","","","Percent of Total Billed Charges","neg_dollar:$0.97;Percent of Total Billed Charges","1.12","92","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.22","Fee Schedule","","1.00","1.00",""
"URSODIOL 500 MG PO TABS","A9270","HCPCS","00591-3005-01","NDC","250","RC","","Facility","Outpatient","500","ME","5.25","5.25","","","","5.25","Fee Schedule","","","","","5.25","Fee Schedule","","","","","5.25","Fee Schedule","","","52","","5.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.73","52","","","Percent of Total Billed Charges","neg_dollar:$2.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.73","52","","","Percent of Total Billed Charges","neg_dollar:$2.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.51","86","","","Percent of Total Billed Charges","neg_dollar:$4.51","3.67","70","","","Percent of Total Billed Charges","neg_dollar:$3.67","","52","","5.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.08;102% of Medicaid interim rate","3.93","75","","","Percent of Total Billed Charges","neg_dollar:$3.93","4.51","86","","","Percent of Total Billed Charges","neg_dollar:$4.51","3.67","70","","","Percent of Total Billed Charges","neg_dollar:$3.67","2.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.99;103.5% of Medicaid interim rate","5.25","150","","","Percent of Total Billed Charges","neg_dollar:$8.11;150% of Medicaid interim rate","4.20","80","","","Percent of Total Billed Charges","neg_dollar:$4.20;Percent of Total Billed Charges","4.83","92","","","Percent of Total Billed Charges","neg_dollar:$4.83","2.73","52","","","Percent of Total Billed Charges","neg_dollar:$2.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.25","Fee Schedule","","2.00","5.00",""
"CIPROFLOXACIN HCL 500 MG PO TABS","A9270","HCPCS","00904-7243-61","NDC","250","RC","","Facility","Outpatient","500","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"BACITRACIN OINTMENT WRAPPER","A9270","HCPCS","57896-145-14","NDC","250","RC","","Facility","Outpatient","500","EA","9.58","9.58","","","","9.58","Fee Schedule","","","","","9.58","Fee Schedule","","","","","9.58","Fee Schedule","","","52","","9.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.98","52","","","Percent of Total Billed Charges","neg_dollar:$4.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.98","52","","","Percent of Total Billed Charges","neg_dollar:$4.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.24","86","","","Percent of Total Billed Charges","neg_dollar:$8.24","6.70","70","","","Percent of Total Billed Charges","neg_dollar:$6.70","","52","","9.58","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.62;102% of Medicaid interim rate","7.18","75","","","Percent of Total Billed Charges","neg_dollar:$7.18","8.24","86","","","Percent of Total Billed Charges","neg_dollar:$8.24","6.70","70","","","Percent of Total Billed Charges","neg_dollar:$6.70","5.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.46;103.5% of Medicaid interim rate","9.58","150","","","Percent of Total Billed Charges","neg_dollar:$14.81;150% of Medicaid interim rate","7.66","80","","","Percent of Total Billed Charges","neg_dollar:$7.66;Percent of Total Billed Charges","8.81","92","","","Percent of Total Billed Charges","neg_dollar:$8.81","4.98","52","","","Percent of Total Billed Charges","neg_dollar:$4.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","9.58","Fee Schedule","","4.00","9.00",""
"LEVOFLOXACIN 500 MG PO TABS","A9270","HCPCS","00904-6352-61","NDC","250","RC","","Facility","Outpatient","500","ME","0.93","0.93","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","52","","0.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","","52","","0.93","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.70","75","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;103.5% of Medicaid interim rate","0.93","150","","","Percent of Total Billed Charges","neg_dollar:$1.45;150% of Medicaid interim rate","0.75","80","","","Percent of Total Billed Charges","neg_dollar:$0.75;Percent of Total Billed Charges","0.86","92","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.93","Fee Schedule","","1.00","1.00",""
"BACITRACIN OINTMENT WRAPPER","A9270","HCPCS","00713-0280-31","NDC","250","RC","","Facility","Outpatient","500","EA","12.95","12.95","","","","12.95","Fee Schedule","","","","","12.95","Fee Schedule","","","","","12.95","Fee Schedule","","","52","","12.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.73","52","","","Percent of Total Billed Charges","neg_dollar:$6.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.73","52","","","Percent of Total Billed Charges","neg_dollar:$6.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.13","86","","","Percent of Total Billed Charges","neg_dollar:$11.13","9.06","70","","","Percent of Total Billed Charges","neg_dollar:$9.06","","52","","12.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.60;102% of Medicaid interim rate","9.71","75","","","Percent of Total Billed Charges","neg_dollar:$9.71","11.13","86","","","Percent of Total Billed Charges","neg_dollar:$11.13","9.06","70","","","Percent of Total Billed Charges","neg_dollar:$9.06","7.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.38;103.5% of Medicaid interim rate","12.95","150","","","Percent of Total Billed Charges","neg_dollar:$20.02;150% of Medicaid interim rate","10.36","80","","","Percent of Total Billed Charges","neg_dollar:$10.36;Percent of Total Billed Charges","11.91","92","","","Percent of Total Billed Charges","neg_dollar:$11.91","6.73","52","","","Percent of Total Billed Charges","neg_dollar:$6.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.95","Fee Schedule","","6.00","12.00",""
"VALACYCLOVIR HCL 500 MG PO TABS","A9270","HCPCS","50268-788-11","NDC","250","RC","","Facility","Outpatient","500","ME","2.60","2.60","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","52","","2.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","","52","","2.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.52;102% of Medicaid interim rate","1.95","75","","","Percent of Total Billed Charges","neg_dollar:$1.95","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","1.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.48;103.5% of Medicaid interim rate","2.60","150","","","Percent of Total Billed Charges","neg_dollar:$4.01;150% of Medicaid interim rate","2.08","80","","","Percent of Total Billed Charges","neg_dollar:$2.08;Percent of Total Billed Charges","2.39","92","","","Percent of Total Billed Charges","neg_dollar:$2.39","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.60","Fee Schedule","","1.00","2.00",""
"METFORMIN HCL 500 MG PO TABS","A9270","HCPCS","60687-155-11","NDC","250","RC","","Facility","Outpatient","500","ME","0.89","0.89","","","","0.89","Fee Schedule","","","","","0.89","Fee Schedule","","","","","0.89","Fee Schedule","","","52","","0.89","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","70","","","Percent of Total Billed Charges","neg_dollar:$0.62","","52","","0.89","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% of Medicaid interim rate","0.67","75","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","70","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.89","150","","","Percent of Total Billed Charges","neg_dollar:$1.38;150% of Medicaid interim rate","0.71","80","","","Percent of Total Billed Charges","neg_dollar:$0.71;Percent of Total Billed Charges","0.82","92","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.89","Fee Schedule","","1.00","1.00",""
"ACETAMINOPHEN 500 MG PO TABS","A9270","HCPCS","57896-201-01","NDC","250","RC","","Facility","Outpatient","500","ME","0.25","0.25","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","","52","","0.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% of Medicaid interim rate","0.18","75","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.25","150","","","Percent of Total Billed Charges","neg_dollar:$0.38;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.25","Fee Schedule","","1.00","1.00",""
"METRONIDAZOLE 500 MG PO TABS","A9270","HCPCS","60687-550-01","NDC","250","RC","","Facility","Outpatient","500","ME","1.90","1.90","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","52","","1.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","","52","","1.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% of Medicaid interim rate","1.42","75","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;103.5% of Medicaid interim rate","1.90","150","","","Percent of Total Billed Charges","neg_dollar:$2.93;150% of Medicaid interim rate","1.52","80","","","Percent of Total Billed Charges","neg_dollar:$1.52;Percent of Total Billed Charges","1.74","92","","","Percent of Total Billed Charges","neg_dollar:$1.74","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.90","Fee Schedule","","1.00","1.00",""
"ACETAMINOPHEN 500 MG PO TABS","A9270","HCPCS","00904-6730-61","NDC","637","RC","","Facility","Outpatient","500","ME","0.27","0.27","","","","0.27","Fee Schedule","","","","","0.27","Fee Schedule","101% of Medicare Fee Schedule","","","","0.27","Fee Schedule","","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.24","86","","","Percent of Total Billed Charges","neg_dollar:$0.24","0.19","70","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.16;102% of Medicaid interim rate","0.20","75","","","Percent of Total Billed Charges","neg_dollar:$0.20","0.24","86","","","Percent of Total Billed Charges","neg_dollar:$0.24","0.19","70","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.15;103.5% of Medicaid interim rate","0.27","150","","","Percent of Total Billed Charges","neg_dollar:$0.43;150% of Medicaid interim rate","0.22","80","","","Percent of Total Billed Charges","neg_dollar:$0.22;Percent of Total Billed Charges","0.25","92","","","Percent of Total Billed Charges","neg_dollar:$0.25","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BACITRACIN OINTMENT WRAPPER","A9270","HCPCS","00904-7023-67","NDC","637","RC","","Facility","Outpatient","500","EA","10.65","10.65","","","","10.65","Fee Schedule","","","","","10.65","Fee Schedule","101% of Medicare Fee Schedule","","","","10.65","Fee Schedule","","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.15","86","","","Percent of Total Billed Charges","neg_dollar:$9.15","7.45","70","","","Percent of Total Billed Charges","neg_dollar:$7.45","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.25;102% of Medicaid interim rate","7.98","75","","","Percent of Total Billed Charges","neg_dollar:$7.98","9.15","86","","","Percent of Total Billed Charges","neg_dollar:$9.15","7.45","70","","","Percent of Total Billed Charges","neg_dollar:$7.45","6.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.07;103.5% of Medicaid interim rate","10.65","150","","","Percent of Total Billed Charges","neg_dollar:$16.46;150% of Medicaid interim rate","8.52","80","","","Percent of Total Billed Charges","neg_dollar:$8.52;Percent of Total Billed Charges","9.79","92","","","Percent of Total Billed Charges","neg_dollar:$9.79","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.53","52","","","Percent of Total Billed Charges","neg_dollar:$5.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"METRONIDAZOLE 500 MG PO TABS","A9270","HCPCS","60687-550-11","NDC","250","RC","","Facility","Outpatient","500","ME","1.90","1.90","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","52","","1.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","","52","","1.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% of Medicaid interim rate","1.42","75","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;103.5% of Medicaid interim rate","1.90","150","","","Percent of Total Billed Charges","neg_dollar:$2.93;150% of Medicaid interim rate","1.52","80","","","Percent of Total Billed Charges","neg_dollar:$1.52;Percent of Total Billed Charges","1.74","92","","","Percent of Total Billed Charges","neg_dollar:$1.74","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.90","Fee Schedule","","1.00","1.00",""
"ACETAMINOPHEN 500 MG PO TABS","A9270","HCPCS","00904-6730-61","NDC","250","RC","","Facility","Outpatient","500","ME","0.26","0.26","","","","0.26","Fee Schedule","","","","","0.26","Fee Schedule","","","","","0.26","Fee Schedule","","","52","","0.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.22","86","","","Percent of Total Billed Charges","neg_dollar:$0.22","0.18","70","","","Percent of Total Billed Charges","neg_dollar:$0.18","","52","","0.26","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.15;102% of Medicaid interim rate","0.19","75","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.22","86","","","Percent of Total Billed Charges","neg_dollar:$0.22","0.18","70","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.26","150","","","Percent of Total Billed Charges","neg_dollar:$0.40;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.26","Fee Schedule","","1.00","1.00",""
"NAPROXEN 500 MG PO TABS","A9270","HCPCS","60687-491-11","NDC","250","RC","","Facility","Outpatient","500","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"AMOXICILLIN 500 MG PO CAPS","A9270","HCPCS","00093-3109-53","NDC","250","RC","","Facility","Outpatient","500","ME","0.83","0.83","","","","0.83","Fee Schedule","","","","","0.83","Fee Schedule","","","","","0.83","Fee Schedule","","","52","","0.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","52","","","Percent of Total Billed Charges","neg_dollar:$0.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","52","","","Percent of Total Billed Charges","neg_dollar:$0.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","86","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.58","70","","","Percent of Total Billed Charges","neg_dollar:$0.58","","52","","0.83","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% of Medicaid interim rate","0.62","75","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.71","86","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.58","70","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;103.5% of Medicaid interim rate","0.83","150","","","Percent of Total Billed Charges","neg_dollar:$1.28;150% of Medicaid interim rate","0.66","80","","","Percent of Total Billed Charges","neg_dollar:$0.66;Percent of Total Billed Charges","0.76","92","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.43","52","","","Percent of Total Billed Charges","neg_dollar:$0.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.83","Fee Schedule","","1.00","1.00",""
"ASCORBIC ACID 500 MG PO TABS","A9270","HCPCS","00904-0523-61","NDC","250","RC","","Facility","Outpatient","500","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"CEPHALEXIN 500 MG PO CAPS","A9270","HCPCS","50268-152-11","NDC","250","RC","","Facility","Outpatient","500","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"AMOXICILLIN 500 MG PO CAPS","A9270","HCPCS","00093-3109-53","NDC","637","RC","","Facility","Outpatient","500","ME","0.79","0.79","","","","0.79","Fee Schedule","","","","","0.79","Fee Schedule","101% of Medicare Fee Schedule","","","","0.79","Fee Schedule","","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.59","75","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.79","150","","","Percent of Total Billed Charges","neg_dollar:$1.23;150% of Medicaid interim rate","0.63","80","","","Percent of Total Billed Charges","neg_dollar:$0.63;Percent of Total Billed Charges","0.73","92","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ASCORBIC ACID 500 MG PO TABS","A9270","HCPCS","00904-0523-61","NDC","637","RC","","Facility","Outpatient","500","ME","0.60","0.60","","","","0.60","Fee Schedule","","","","","0.60","Fee Schedule","101% of Medicare Fee Schedule","","","","0.60","Fee Schedule","","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","86","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% of Medicaid interim rate","0.45","75","","","Percent of Total Billed Charges","neg_dollar:$0.45","0.52","86","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.34;103.5% of Medicaid interim rate","0.60","150","","","Percent of Total Billed Charges","neg_dollar:$0.93;150% of Medicaid interim rate","0.48","80","","","Percent of Total Billed Charges","neg_dollar:$0.48;Percent of Total Billed Charges","0.55","92","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BACITRACIN OINTMENT WRAPPER","A9270","HCPCS","57896-145-14","NDC","637","RC","","Facility","Outpatient","500","EA","5.20","5.20","","","","5.20","Fee Schedule","","","","","5.20","Fee Schedule","101% of Medicare Fee Schedule","","","","5.20","Fee Schedule","","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.47","86","","","Percent of Total Billed Charges","neg_dollar:$4.47","3.64","70","","","Percent of Total Billed Charges","neg_dollar:$3.64","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","3.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.05;102% of Medicaid interim rate","3.90","75","","","Percent of Total Billed Charges","neg_dollar:$3.90","4.47","86","","","Percent of Total Billed Charges","neg_dollar:$4.47","3.64","70","","","Percent of Total Billed Charges","neg_dollar:$3.64","2.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.96;103.5% of Medicaid interim rate","5.20","150","","","Percent of Total Billed Charges","neg_dollar:$8.04;150% of Medicaid interim rate","4.16","80","","","Percent of Total Billed Charges","neg_dollar:$4.16;Percent of Total Billed Charges","4.78","92","","","Percent of Total Billed Charges","neg_dollar:$4.78","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","52","","","Percent of Total Billed Charges","neg_dollar:$2.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"METFORMIN HCL 500 MG PO TABS","A9270","HCPCS","60687-155-11","NDC","637","RC","","Facility","Outpatient","500","ME","0.86","0.86","","","","0.86","Fee Schedule","","","","","0.86","Fee Schedule","101% of Medicare Fee Schedule","","","","0.86","Fee Schedule","","0.45","52","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","86","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.60","70","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.45","52","","","Percent of Total Billed Charges","neg_dollar:$0.45;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;102% of Medicaid interim rate","0.65","75","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.74","86","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.60","70","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.49;103.5% of Medicaid interim rate","0.86","150","","","Percent of Total Billed Charges","neg_dollar:$1.34;150% of Medicaid interim rate","0.69","80","","","Percent of Total Billed Charges","neg_dollar:$0.69;Percent of Total Billed Charges","0.79","92","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.45","52","","","Percent of Total Billed Charges","neg_dollar:$0.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","52","","","Percent of Total Billed Charges","neg_dollar:$0.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METFORMIN HCL ER 500 MG PO TB24","A9270","HCPCS","50268-550-11","NDC","637","RC","","Facility","Outpatient","500","ME","1.22","1.22","","","","1.22","Fee Schedule","","","","","1.22","Fee Schedule","101% of Medicare Fee Schedule","","","","1.22","Fee Schedule","","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% of Medicaid interim rate","0.91","75","","","Percent of Total Billed Charges","neg_dollar:$0.91","1.05","86","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;103.5% of Medicaid interim rate","1.22","150","","","Percent of Total Billed Charges","neg_dollar:$1.89;150% of Medicaid interim rate","0.98","80","","","Percent of Total Billed Charges","neg_dollar:$0.98;Percent of Total Billed Charges","1.12","92","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"VALACYCLOVIR HCL 500 MG PO TABS","A9270","HCPCS","50268-788-11","NDC","637","RC","","Facility","Outpatient","500","ME","2.60","2.60","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","101% of Medicare Fee Schedule","","","","2.60","Fee Schedule","","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.52;102% of Medicaid interim rate","1.95","75","","","Percent of Total Billed Charges","neg_dollar:$1.95","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","1.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.48;103.5% of Medicaid interim rate","2.60","150","","","Percent of Total Billed Charges","neg_dollar:$4.01;150% of Medicaid interim rate","2.08","80","","","Percent of Total Billed Charges","neg_dollar:$2.08;Percent of Total Billed Charges","2.39","92","","","Percent of Total Billed Charges","neg_dollar:$2.39","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"DIVALPROEX SODIUM ER 500 MG PO TB24","A9270","HCPCS","68084-415-11","NDC","637","RC","","Facility","Outpatient","500","ME","3.65","3.65","","","","3.65","Fee Schedule","","","","","3.65","Fee Schedule","101% of Medicare Fee Schedule","","","","3.65","Fee Schedule","","1.89","52","","","Percent of Total Billed Charges","neg_dollar:$1.89;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.13","86","","","Percent of Total Billed Charges","neg_dollar:$3.13","2.55","70","","","Percent of Total Billed Charges","neg_dollar:$2.55","1.89","52","","","Percent of Total Billed Charges","neg_dollar:$1.89;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.14;102% of Medicaid interim rate","2.73","75","","","Percent of Total Billed Charges","neg_dollar:$2.73","3.13","86","","","Percent of Total Billed Charges","neg_dollar:$3.13","2.55","70","","","Percent of Total Billed Charges","neg_dollar:$2.55","2.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.08;103.5% of Medicaid interim rate","3.65","150","","","Percent of Total Billed Charges","neg_dollar:$5.64;150% of Medicaid interim rate","2.92","80","","","Percent of Total Billed Charges","neg_dollar:$2.92;Percent of Total Billed Charges","3.35","92","","","Percent of Total Billed Charges","neg_dollar:$3.35","1.89","52","","","Percent of Total Billed Charges","neg_dollar:$1.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.89","52","","","Percent of Total Billed Charges","neg_dollar:$1.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"LEVOFLOXACIN 500 MG PO TABS","A9270","HCPCS","00904-6352-61","NDC","637","RC","","Facility","Outpatient","500","ME","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","101% of Medicare Fee Schedule","","","","0.85","Fee Schedule","","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% of Medicaid interim rate","0.64","75","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.32;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LEVETIRACETAM 500 MG PO TABS","A9270","HCPCS","51079-821-01","NDC","637","RC","","Facility","Outpatient","500","ME","1.38","1.38","","","","1.38","Fee Schedule","","","","","1.38","Fee Schedule","101% of Medicare Fee Schedule","","","","1.38","Fee Schedule","","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.19","86","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.81;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.19","86","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.38","150","","","Percent of Total Billed Charges","neg_dollar:$2.14;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.27","92","","","Percent of Total Billed Charges","neg_dollar:$1.27","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LEVETIRACETAM 500 MG PO TABS","A9270","HCPCS","51079-821-20","NDC","637","RC","","Facility","Outpatient","500","ME","1.03","1.03","","","","1.03","Fee Schedule","","","","","1.03","Fee Schedule","101% of Medicare Fee Schedule","","","","1.03","Fee Schedule","","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","86","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% of Medicaid interim rate","0.77","75","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.88","86","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;103.5% of Medicaid interim rate","1.03","150","","","Percent of Total Billed Charges","neg_dollar:$1.59;150% of Medicaid interim rate","0.82","80","","","Percent of Total Billed Charges","neg_dollar:$0.82;Percent of Total Billed Charges","0.95","92","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CEPHALEXIN 500 MG PO CAPS","A9270","HCPCS","50268-152-11","NDC","637","RC","","Facility","Outpatient","500","ME","1.68","1.68","","","","1.68","Fee Schedule","","","","","1.68","Fee Schedule","101% of Medicare Fee Schedule","","","","1.68","Fee Schedule","","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.44","86","","","Percent of Total Billed Charges","neg_dollar:$1.44","1.17","70","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% of Medicaid interim rate","1.26","75","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.44","86","","","Percent of Total Billed Charges","neg_dollar:$1.44","1.17","70","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.68","150","","","Percent of Total Billed Charges","neg_dollar:$2.60;150% of Medicaid interim rate","1.34","80","","","Percent of Total Billed Charges","neg_dollar:$1.34;Percent of Total Billed Charges","1.54","92","","","Percent of Total Billed Charges","neg_dollar:$1.54","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METRONIDAZOLE 500 MG PO TABS","A9270","HCPCS","60687-550-11","NDC","637","RC","","Facility","Outpatient","500","ME","1.90","1.90","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","101% of Medicare Fee Schedule","","","","1.90","Fee Schedule","","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% of Medicaid interim rate","1.42","75","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;103.5% of Medicaid interim rate","1.90","150","","","Percent of Total Billed Charges","neg_dollar:$2.93;150% of Medicaid interim rate","1.52","80","","","Percent of Total Billed Charges","neg_dollar:$1.52;Percent of Total Billed Charges","1.74","92","","","Percent of Total Billed Charges","neg_dollar:$1.74","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ACETAMINOPHEN 500 MG PO TABS","A9270","HCPCS","57896-201-01","NDC","637","RC","","Facility","Outpatient","500","ME","0.27","0.27","","","","0.27","Fee Schedule","","","","","0.27","Fee Schedule","101% of Medicare Fee Schedule","","","","0.27","Fee Schedule","","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.23","86","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.19","70","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.16;102% of Medicaid interim rate","0.20","75","","","Percent of Total Billed Charges","neg_dollar:$0.20","0.23","86","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.19","70","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.15;103.5% of Medicaid interim rate","0.27","150","","","Percent of Total Billed Charges","neg_dollar:$0.42;150% of Medicaid interim rate","0.21","80","","","Percent of Total Billed Charges","neg_dollar:$0.21;Percent of Total Billed Charges","0.25","92","","","Percent of Total Billed Charges","neg_dollar:$0.25","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"NAPROXEN 500 MG PO TABS","A9270","HCPCS","60687-491-11","NDC","637","RC","","Facility","Outpatient","500","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TAKE HOME CEPHALEXIN 500 MG PO CAPS (QTY:SIX)","A9270","HCPCS","00093-3147-01","NDC","253","RC","","Facility","Outpatient","1","UN","11.95","11.95","11.95","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;101% Medicare Outpatient Cost to Charge Ratio of 52%","11.95","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.02;102% of Medicaid interim rate","8.96","75","","","Percent of Total Billed Charges","neg_dollar:$8.96","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.81;103.5% of Medicaid interim rate","11.95","150","","","Percent of Total Billed Charges","neg_dollar:$18.47;150% of Medicaid interim rate","9.56","80","","","Percent of Total Billed Charges","neg_dollar:$9.56;Percent of Total Billed Charges","10.99","92","","","Percent of Total Billed Charges","neg_dollar:$10.99","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","11.00",""
"TAKE HOME LEVOFLOXACIN 500 MG PO TABS (QTY:TWO)","A9270","HCPCS","00904-6352-61","NDC","253","RC","","Facility","Outpatient","1","UN","11.05","11.05","11.05","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","5.74","52","","","Percent of Total Billed Charges","neg_dollar:$5.74;101% Medicare Outpatient Cost to Charge Ratio of 52%","11.05","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","5.74","52","","","Percent of Total Billed Charges","neg_dollar:$5.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.74","52","","","Percent of Total Billed Charges","neg_dollar:$5.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.74","52","","","Percent of Total Billed Charges","neg_dollar:$5.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.50","86","","","Percent of Total Billed Charges","neg_dollar:$9.50","7.73","70","","","Percent of Total Billed Charges","neg_dollar:$7.73","5.74","52","","","Percent of Total Billed Charges","neg_dollar:$5.74;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.49;102% of Medicaid interim rate","8.28","75","","","Percent of Total Billed Charges","neg_dollar:$8.28","9.50","86","","","Percent of Total Billed Charges","neg_dollar:$9.50","7.73","70","","","Percent of Total Billed Charges","neg_dollar:$7.73","6.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.29;103.5% of Medicaid interim rate","11.05","150","","","Percent of Total Billed Charges","neg_dollar:$17.08;150% of Medicaid interim rate","8.84","80","","","Percent of Total Billed Charges","neg_dollar:$8.84;Percent of Total Billed Charges","10.16","92","","","Percent of Total Billed Charges","neg_dollar:$10.16","5.74","52","","","Percent of Total Billed Charges","neg_dollar:$5.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.74","52","","","Percent of Total Billed Charges","neg_dollar:$5.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","11.00",""
"TAKE HOME METRONIDAZOLE PO TABS (QTY:14)","A9270","HCPCS","09999-4101-72","NDC","253","RC","","Facility","Outpatient","1","UN","1.31","1.31","1.31","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","1.31","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.13","86","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.91","70","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% of Medicaid interim rate","0.98","75","","","Percent of Total Billed Charges","neg_dollar:$0.98","1.13","86","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.91","70","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.31","150","","","Percent of Total Billed Charges","neg_dollar:$2.03;150% of Medicaid interim rate","1.05","80","","","Percent of Total Billed Charges","neg_dollar:$1.05;Percent of Total Billed Charges","1.20","92","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS","A9270","HCPCS","65862-502-20","NDC","637","RC","","Facility","Outpatient","1","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","101% of Medicare Fee Schedule","","","","1.55","Fee Schedule","","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS","A9270","HCPCS","65862-502-20","NDC","250","RC","","Facility","Outpatient","1","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.55","Fee Schedule","","1.00","1.00",""
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","A9270","HCPCS","00406-0123-23","NDC","250","RC","","Facility","Outpatient","1","ME","1.61","1.61","","","","1.61","Fee Schedule","","","","","1.61","Fee Schedule","","","","","1.61","Fee Schedule","","","52","","1.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.12","70","","","Percent of Total Billed Charges","neg_dollar:$1.12","","52","","1.61","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.12","70","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.61","150","","","Percent of Total Billed Charges","neg_dollar:$2.49;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.48","92","","","Percent of Total Billed Charges","neg_dollar:$1.48","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.61","Fee Schedule","","1.00","1.00",""
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","A9270","HCPCS","60687-396-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.65","1.65","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","","52","","1.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.23","75","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.65","150","","","Percent of Total Billed Charges","neg_dollar:$2.55;150% of Medicaid interim rate","1.32","80","","","Percent of Total Billed Charges","neg_dollar:$1.32;Percent of Total Billed Charges","1.51","92","","","Percent of Total Billed Charges","neg_dollar:$1.51","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.65","Fee Schedule","","1.00","1.00",""
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","A9270","HCPCS","60687-396-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.59","1.59","","","","1.59","Fee Schedule","","","","","1.59","Fee Schedule","","","","","1.59","Fee Schedule","","","52","","1.59","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.59","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.19","75","","","Percent of Total Billed Charges","neg_dollar:$1.19","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.90;103.5% of Medicaid interim rate","1.59","150","","","Percent of Total Billed Charges","neg_dollar:$2.46;150% of Medicaid interim rate","1.27","80","","","Percent of Total Billed Charges","neg_dollar:$1.27;Percent of Total Billed Charges","1.46","92","","","Percent of Total Billed Charges","neg_dollar:$1.46","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.59","Fee Schedule","","1.00","1.00",""
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","A9270","HCPCS","00406-0123-23","NDC","637","RC","","Facility","Outpatient","1","ME","2.08","2.08","","","","2.08","Fee Schedule","","","","","2.08","Fee Schedule","101% of Medicare Fee Schedule","","","","2.08","Fee Schedule","","1.08","52","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.79","86","","","Percent of Total Billed Charges","neg_dollar:$1.79","1.45","70","","","Percent of Total Billed Charges","neg_dollar:$1.45","1.08","52","","","Percent of Total Billed Charges","neg_dollar:$1.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.22;102% of Medicaid interim rate","1.56","75","","","Percent of Total Billed Charges","neg_dollar:$1.56","1.79","86","","","Percent of Total Billed Charges","neg_dollar:$1.79","1.45","70","","","Percent of Total Billed Charges","neg_dollar:$1.45","1.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.18;103.5% of Medicaid interim rate","2.08","150","","","Percent of Total Billed Charges","neg_dollar:$3.21;150% of Medicaid interim rate","1.66","80","","","Percent of Total Billed Charges","neg_dollar:$1.66;Percent of Total Billed Charges","1.91","92","","","Percent of Total Billed Charges","neg_dollar:$1.91","1.08","52","","","Percent of Total Billed Charges","neg_dollar:$1.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","52","","","Percent of Total Billed Charges","neg_dollar:$1.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","A9270","HCPCS","60687-396-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.73","1.73","","","","1.73","Fee Schedule","","","","","1.73","Fee Schedule","101% of Medicare Fee Schedule","","","","1.73","Fee Schedule","","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.73","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.73","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.49","86","","","Percent of Total Billed Charges","neg_dollar:$1.49","1.21","70","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.01;102% of Medicaid interim rate","1.30","75","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.49","86","","","Percent of Total Billed Charges","neg_dollar:$1.49","1.21","70","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.98;103.5% of Medicaid interim rate","1.73","150","","","Percent of Total Billed Charges","neg_dollar:$2.68;150% of Medicaid interim rate","1.38","80","","","Percent of Total Billed Charges","neg_dollar:$1.38;Percent of Total Billed Charges","1.59","92","","","Percent of Total Billed Charges","neg_dollar:$1.59","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TAKE HOME HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TAB (QTY:SIX)","A9270","HCPCS","00406-0123-62","NDC","253","RC","","Facility","Outpatient","1","ME","10.75","10.75","10.75","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;101% Medicare Outpatient Cost to Charge Ratio of 52%","10.75","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.24","86","","","Percent of Total Billed Charges","neg_dollar:$9.24","7.52","70","","","Percent of Total Billed Charges","neg_dollar:$7.52","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.31;102% of Medicaid interim rate","8.06","75","","","Percent of Total Billed Charges","neg_dollar:$8.06","9.24","86","","","Percent of Total Billed Charges","neg_dollar:$9.24","7.52","70","","","Percent of Total Billed Charges","neg_dollar:$7.52","6.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.12;103.5% of Medicaid interim rate","10.75","150","","","Percent of Total Billed Charges","neg_dollar:$16.62;150% of Medicaid interim rate","8.60","80","","","Percent of Total Billed Charges","neg_dollar:$8.60;Percent of Total Billed Charges","9.89","92","","","Percent of Total Billed Charges","neg_dollar:$9.89","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"TAKE HOME HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TAB (QTY:SIX)","A9270","HCPCS","53746-109-01","NDC","253","RC","","Facility","Outpatient","1","ME","10.75","10.75","10.75","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;101% Medicare Outpatient Cost to Charge Ratio of 52%","10.75","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.24","86","","","Percent of Total Billed Charges","neg_dollar:$9.24","7.52","70","","","Percent of Total Billed Charges","neg_dollar:$7.52","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.31;102% of Medicaid interim rate","8.06","75","","","Percent of Total Billed Charges","neg_dollar:$8.06","9.24","86","","","Percent of Total Billed Charges","neg_dollar:$9.24","7.52","70","","","Percent of Total Billed Charges","neg_dollar:$7.52","6.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.12;103.5% of Medicaid interim rate","10.75","150","","","Percent of Total Billed Charges","neg_dollar:$16.62;150% of Medicaid interim rate","8.60","80","","","Percent of Total Billed Charges","neg_dollar:$8.60;Percent of Total Billed Charges","9.89","92","","","Percent of Total Billed Charges","neg_dollar:$9.89","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"TAKE HOME HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TAB (QTY:SIX)","A9270","HCPCS","00406-0123-62","NDC","250","RC","","Facility","Outpatient","1","ME","10.75","10.75","","","","10.75","Fee Schedule","","","","","10.75","Fee Schedule","","","","","10.75","Fee Schedule","","","52","","10.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.24","86","","","Percent of Total Billed Charges","neg_dollar:$9.24","7.52","70","","","Percent of Total Billed Charges","neg_dollar:$7.52","","52","","10.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.31;102% of Medicaid interim rate","8.06","75","","","Percent of Total Billed Charges","neg_dollar:$8.06","9.24","86","","","Percent of Total Billed Charges","neg_dollar:$9.24","7.52","70","","","Percent of Total Billed Charges","neg_dollar:$7.52","6.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.12;103.5% of Medicaid interim rate","10.75","150","","","Percent of Total Billed Charges","neg_dollar:$16.62;150% of Medicaid interim rate","8.60","80","","","Percent of Total Billed Charges","neg_dollar:$8.60;Percent of Total Billed Charges","9.89","92","","","Percent of Total Billed Charges","neg_dollar:$9.89","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.75","Fee Schedule","","5.00","10.00",""
"PROMETHAZINE-CODEINE 6.25-10 MG/5ML PO SOLN","A9270","HCPCS","27808-065-02","NDC","250","RC","","Facility","Outpatient","1","UN","10.85","10.85","","","","10.85","Fee Schedule","","","","","10.85","Fee Schedule","","","","","10.85","Fee Schedule","","","52","","10.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.64","52","","","Percent of Total Billed Charges","neg_dollar:$5.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.64","52","","","Percent of Total Billed Charges","neg_dollar:$5.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.33","86","","","Percent of Total Billed Charges","neg_dollar:$9.33","7.59","70","","","Percent of Total Billed Charges","neg_dollar:$7.59","","52","","10.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.37;102% of Medicaid interim rate","8.13","75","","","Percent of Total Billed Charges","neg_dollar:$8.13","9.33","86","","","Percent of Total Billed Charges","neg_dollar:$9.33","7.59","70","","","Percent of Total Billed Charges","neg_dollar:$7.59","6.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.18;103.5% of Medicaid interim rate","10.85","150","","","Percent of Total Billed Charges","neg_dollar:$16.77;150% of Medicaid interim rate","8.68","80","","","Percent of Total Billed Charges","neg_dollar:$8.68;Percent of Total Billed Charges","9.98","92","","","Percent of Total Billed Charges","neg_dollar:$9.98","5.64","52","","","Percent of Total Billed Charges","neg_dollar:$5.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.85","Fee Schedule","","5.00","10.00",""
"PROMETHAZINE-CODEINE 6.25-10 MG/5ML PO SOLN","A9270","HCPCS","27808-065-02","NDC","637","RC","","Facility","Outpatient","1","UN","10.85","10.85","","","","10.85","Fee Schedule","","","","","10.85","Fee Schedule","101% of Medicare Fee Schedule","","","","10.85","Fee Schedule","","5.64","52","","","Percent of Total Billed Charges","neg_dollar:$5.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.33","86","","","Percent of Total Billed Charges","neg_dollar:$9.33","7.59","70","","","Percent of Total Billed Charges","neg_dollar:$7.59","5.64","52","","","Percent of Total Billed Charges","neg_dollar:$5.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.37;102% of Medicaid interim rate","8.13","75","","","Percent of Total Billed Charges","neg_dollar:$8.13","9.33","86","","","Percent of Total Billed Charges","neg_dollar:$9.33","7.59","70","","","Percent of Total Billed Charges","neg_dollar:$7.59","6.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.18;103.5% of Medicaid interim rate","10.85","150","","","Percent of Total Billed Charges","neg_dollar:$16.77;150% of Medicaid interim rate","8.68","80","","","Percent of Total Billed Charges","neg_dollar:$8.68;Percent of Total Billed Charges","9.98","92","","","Percent of Total Billed Charges","neg_dollar:$9.98","5.64","52","","","Percent of Total Billed Charges","neg_dollar:$5.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.64","52","","","Percent of Total Billed Charges","neg_dollar:$5.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"CARBAMIDE PEROXIDE 6.5 % OT SOLN","A9270","HCPCS","00904-6627-35","NDC","250","RC","","Facility","Outpatient","1","UN","12.60","12.60","","","","12.60","Fee Schedule","","","","","12.60","Fee Schedule","","","","","12.60","Fee Schedule","","","52","","12.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.55","52","","","Percent of Total Billed Charges","neg_dollar:$6.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.55","52","","","Percent of Total Billed Charges","neg_dollar:$6.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.83","86","","","Percent of Total Billed Charges","neg_dollar:$10.83","8.81","70","","","Percent of Total Billed Charges","neg_dollar:$8.81","","52","","12.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.40;102% of Medicaid interim rate","9.45","75","","","Percent of Total Billed Charges","neg_dollar:$9.45","10.83","86","","","Percent of Total Billed Charges","neg_dollar:$10.83","8.81","70","","","Percent of Total Billed Charges","neg_dollar:$8.81","7.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.18;103.5% of Medicaid interim rate","12.60","150","","","Percent of Total Billed Charges","neg_dollar:$19.48;150% of Medicaid interim rate","10.08","80","","","Percent of Total Billed Charges","neg_dollar:$10.08;Percent of Total Billed Charges","11.59","92","","","Percent of Total Billed Charges","neg_dollar:$11.59","6.55","52","","","Percent of Total Billed Charges","neg_dollar:$6.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.60","Fee Schedule","","6.00","12.00",""
"GEMFIBROZIL 600 MG PO TABS","A9270","HCPCS","50268-350-11","NDC","250","RC","","Facility","Outpatient","600","ME","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","","52","","1.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.45","Fee Schedule","","1.00","1.00",""
"GUAIFENESIN ER 600 MG PO TB12","A9270","HCPCS","68084-572-01","NDC","250","RC","","Facility","Outpatient","600","ME","1.41","1.41","","","","1.41","Fee Schedule","","","","","1.41","Fee Schedule","","","","","1.41","Fee Schedule","","","52","","1.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.21","86","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.99","70","","","Percent of Total Billed Charges","neg_dollar:$0.99","","52","","1.41","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% of Medicaid interim rate","1.06","75","","","Percent of Total Billed Charges","neg_dollar:$1.06","1.21","86","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.99","70","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.80;103.5% of Medicaid interim rate","1.41","150","","","Percent of Total Billed Charges","neg_dollar:$2.18;150% of Medicaid interim rate","1.13","80","","","Percent of Total Billed Charges","neg_dollar:$1.13;Percent of Total Billed Charges","1.30","92","","","Percent of Total Billed Charges","neg_dollar:$1.30","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.41","Fee Schedule","","1.00","1.00",""
"GUAIFENESIN ER 600 MG PO TB12","A9270","HCPCS","68084-572-11","NDC","250","RC","","Facility","Outpatient","600","ME","2.04","2.04","","","","2.04","Fee Schedule","","","","","2.04","Fee Schedule","","","","","2.04","Fee Schedule","","","52","","2.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.75","86","","","Percent of Total Billed Charges","neg_dollar:$1.75","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","","52","","2.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.75","86","","","Percent of Total Billed Charges","neg_dollar:$1.75","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.04","150","","","Percent of Total Billed Charges","neg_dollar:$3.15;150% of Medicaid interim rate","1.63","80","","","Percent of Total Billed Charges","neg_dollar:$1.63;Percent of Total Billed Charges","1.87","92","","","Percent of Total Billed Charges","neg_dollar:$1.87","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.04","Fee Schedule","","1.00","2.00",""
"GUAIFENESIN ER 600 MG PO TB12","A9270","HCPCS","68084-572-01","NDC","637","RC","","Facility","Outpatient","600","ME","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","101% of Medicare Fee Schedule","","","","2.05","Fee Schedule","","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"GUAIFENESIN ER 600 MG PO TB12","A9270","HCPCS","68084-572-11","NDC","637","RC","","Facility","Outpatient","600","ME","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","101% of Medicare Fee Schedule","","","","2.05","Fee Schedule","","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"GEMFIBROZIL 600 MG PO TABS","A9270","HCPCS","50268-350-11","NDC","637","RC","","Facility","Outpatient","600","ME","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","101% of Medicare Fee Schedule","","","","1.45","Fee Schedule","","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS PO CPEP","A9270","HCPCS","00032-1206-01","NDC","250","RC","","Facility","Outpatient","1","EA","3","3.00","","","","3.00","Fee Schedule","","","","","3.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","3.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.56","52","","","Percent of Total Billed Charges","neg_dollar:$1.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.56","52","","","Percent of Total Billed Charges","neg_dollar:$1.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.58","86","","","Percent of Total Billed Charges","neg_dollar:$2.58","2.09","70","","","Percent of Total Billed Charges","neg_dollar:$2.09","","52","","3.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.76;102% of Medicaid interim rate","2.25","75","","","Percent of Total Billed Charges","neg_dollar:$2.25","2.58","86","","","Percent of Total Billed Charges","neg_dollar:$2.58","2.09","70","","","Percent of Total Billed Charges","neg_dollar:$2.09","1.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.71;103.5% of Medicaid interim rate","3.00","150","","","Percent of Total Billed Charges","neg_dollar:$4.63;150% of Medicaid interim rate","2.40","80","","","Percent of Total Billed Charges","neg_dollar:$2.40;Percent of Total Billed Charges","2.76","92","","","Percent of Total Billed Charges","neg_dollar:$2.76","1.56","52","","","Percent of Total Billed Charges","neg_dollar:$1.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.00","Fee Schedule","","1.00","3.00",""
"CALCIUM CARB-CHOLECALCIFEROL 600-10 MG-MCG PO TABS","A9270","HCPCS","20555-01700","NDC","250","RC","","Facility","Outpatient","1","EA","1.04","1.04","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","52","","1.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.04","150","","","Percent of Total Billed Charges","neg_dollar:$1.61;150% of Medicaid interim rate","0.83","80","","","Percent of Total Billed Charges","neg_dollar:$0.83;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.04","Fee Schedule","","1.00","1.00",""
"CALCIUM CARB-CHOLECALCIFEROL 600-10 MG-MCG PO TABS","A9270","HCPCS","20555-01700","NDC","637","RC","","Facility","Outpatient","1","EA","1.16","1.16","","","","1.16","Fee Schedule","","","","","1.16","Fee Schedule","101% of Medicare Fee Schedule","","","","1.16","Fee Schedule","","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","86","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% of Medicaid interim rate","0.87","75","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.99","86","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.66;103.5% of Medicaid interim rate","1.16","150","","","Percent of Total Billed Charges","neg_dollar:$1.79;150% of Medicaid interim rate","0.92","80","","","Percent of Total Billed Charges","neg_dollar:$0.92;Percent of Total Billed Charges","1.06","92","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BENZOCAINE-MENTHOL 6-10 MG MT LOZG","A9270","HCPCS","78112-01106","NDC","250","RC","","Facility","Outpatient","1","EA","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"BENZOCAINE-MENTHOL 6-10 MG MT LOZG","A9270","HCPCS","78112-01106","NDC","637","RC","","Facility","Outpatient","1","EA","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CALCIUM POLYCARBOPHIL 625 MG PO TABS","A9270","HCPCS","77333-120-25","NDC","637","RC","","Facility","Outpatient","625","ME","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","101% of Medicare Fee Schedule","","","","1.70","Fee Schedule","","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SODIUM BICARBONATE 650 MG PO TABS","A9270","HCPCS","77333-827-10","NDC","250","RC","","Facility","Outpatient","650","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"SODIUM BICARBONATE 650 MG PO TABS","A9270","HCPCS","77333-827-25","NDC","250","RC","","Facility","Outpatient","650","ME","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","","52","","0.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.50;102% of Medicaid interim rate","0.64","75","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.32;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.85","Fee Schedule","","1.00","1.00",""
"MELOXICAM 7.5 MG PO TABS","A9270","HCPCS","50268-525-15","NDC","250","RC","","Facility","Outpatient","1","ME","0.88","0.88","","","","0.88","Fee Schedule","","","","","0.88","Fee Schedule","","","","","0.88","Fee Schedule","","","52","","0.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","86","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","70","","","Percent of Total Billed Charges","neg_dollar:$0.62","","52","","0.88","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% of Medicaid interim rate","0.66","75","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.76","86","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","70","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.50;103.5% of Medicaid interim rate","0.88","150","","","Percent of Total Billed Charges","neg_dollar:$1.37;150% of Medicaid interim rate","0.71","80","","","Percent of Total Billed Charges","neg_dollar:$0.71;Percent of Total Billed Charges","0.81","92","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.88","Fee Schedule","","1.00","1.00",""
"MELOXICAM 7.5 MG PO TABS","A9270","HCPCS","50268-525-15","NDC","637","RC","","Facility","Outpatient","1","ME","0.77","0.77","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","101% of Medicare Fee Schedule","","","","0.77","Fee Schedule","","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.57","75","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.77","150","","","Percent of Total Billed Charges","neg_dollar:$1.19;150% of Medicaid interim rate","0.61","80","","","Percent of Total Billed Charges","neg_dollar:$0.61;Percent of Total Billed Charges","0.71","92","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS","A9270","HCPCS","00406-0124-23","NDC","250","RC","","Facility","Outpatient","1","ME","1.69","1.69","","","","1.69","Fee Schedule","","","","","1.69","Fee Schedule","","","","","1.69","Fee Schedule","","","52","","1.69","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.45","86","","","Percent of Total Billed Charges","neg_dollar:$1.45","1.18","70","","","Percent of Total Billed Charges","neg_dollar:$1.18","","52","","1.69","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.26","75","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.45","86","","","Percent of Total Billed Charges","neg_dollar:$1.45","1.18","70","","","Percent of Total Billed Charges","neg_dollar:$1.18","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.69","150","","","Percent of Total Billed Charges","neg_dollar:$2.61;150% of Medicaid interim rate","1.35","80","","","Percent of Total Billed Charges","neg_dollar:$1.35;Percent of Total Billed Charges","1.55","92","","","Percent of Total Billed Charges","neg_dollar:$1.55","0.87","52","","","Percent of Total Billed Charges","neg_dollar:$0.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.69","Fee Schedule","","1.00","1.00",""
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS","A9270","HCPCS","00406-0124-23","NDC","637","RC","","Facility","Outpatient","1","ME","1.85","1.85","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","101% of Medicare Fee Schedule","","","","1.85","Fee Schedule","","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;103.5% of Medicaid interim rate","1.85","150","","","Percent of Total Billed Charges","neg_dollar:$2.86;150% of Medicaid interim rate","1.48","80","","","Percent of Total Billed Charges","neg_dollar:$1.48;Percent of Total Billed Charges","1.70","92","","","Percent of Total Billed Charges","neg_dollar:$1.70","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CLOPIDOGREL BISULFATE 75 MG PO TABS","A9270","HCPCS","68084-536-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"LEVOTHYROXINE SODIUM 75 MCG PO TABS","A9270","HCPCS","51079-441-01","NDC","250","RC","","Facility","Outpatient","1","EA","1.41","1.41","","","","1.41","Fee Schedule","","","","","1.41","Fee Schedule","","","","","1.41","Fee Schedule","","","52","","1.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.21","86","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.99","70","","","Percent of Total Billed Charges","neg_dollar:$0.99","","52","","1.41","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% of Medicaid interim rate","1.06","75","","","Percent of Total Billed Charges","neg_dollar:$1.06","1.21","86","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.99","70","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.80;103.5% of Medicaid interim rate","1.41","150","","","Percent of Total Billed Charges","neg_dollar:$2.18;150% of Medicaid interim rate","1.13","80","","","Percent of Total Billed Charges","neg_dollar:$1.13;Percent of Total Billed Charges","1.30","92","","","Percent of Total Billed Charges","neg_dollar:$1.30","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.41","Fee Schedule","","1.00","1.00",""
"DICLOFENAC SODIUM 75 MG PO TBEC","A9270","HCPCS","68001-281-06","NDC","250","RC","","Facility","Outpatient","1","EA","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"VENLAFAXINE HCL ER 75 MG PO CP24","A9270","HCPCS","68084-709-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.19","1.19","","","","1.19","Fee Schedule","","","","","1.19","Fee Schedule","","","","","1.19","Fee Schedule","","","52","","1.19","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","86","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.83","70","","","Percent of Total Billed Charges","neg_dollar:$0.83","","52","","1.19","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.02","86","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.83","70","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.19","150","","","Percent of Total Billed Charges","neg_dollar:$1.84;150% of Medicaid interim rate","0.95","80","","","Percent of Total Billed Charges","neg_dollar:$0.95;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.19","Fee Schedule","","1.00","1.00",""
"LEVOTHYROXINE SODIUM 75 MCG PO TABS","A9270","HCPCS","60687-475-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.42","1.42","","","","1.42","Fee Schedule","","","","","1.42","Fee Schedule","","","","","1.42","Fee Schedule","","","52","","1.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.22","86","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","70","","","Percent of Total Billed Charges","neg_dollar:$0.99","","52","","1.42","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% of Medicaid interim rate","1.07","75","","","Percent of Total Billed Charges","neg_dollar:$1.07","1.22","86","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","70","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.81;103.5% of Medicaid interim rate","1.42","150","","","Percent of Total Billed Charges","neg_dollar:$2.20;150% of Medicaid interim rate","1.14","80","","","Percent of Total Billed Charges","neg_dollar:$1.14;Percent of Total Billed Charges","1.31","92","","","Percent of Total Billed Charges","neg_dollar:$1.31","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.42","Fee Schedule","","1.00","1.00",""
"CLOPIDOGREL BISULFATE 75 MG PO TABS","A9270","HCPCS","68084-536-11","NDC","637","RC","","Facility","Outpatient","1","EA","1.11","1.11","","","","1.11","Fee Schedule","","","","","1.11","Fee Schedule","101% of Medicare Fee Schedule","","","","1.11","Fee Schedule","","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% of Medicaid interim rate","0.83","75","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;103.5% of Medicaid interim rate","1.11","150","","","Percent of Total Billed Charges","neg_dollar:$1.72;150% of Medicaid interim rate","0.89","80","","","Percent of Total Billed Charges","neg_dollar:$0.89;Percent of Total Billed Charges","1.02","92","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS","A9270","HCPCS","64380-799-01","NDC","637","RC","","Facility","Outpatient","1","EA","3.25","3.25","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","101% of Medicare Fee Schedule","","","","3.25","Fee Schedule","","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.90;102% of Medicaid interim rate","2.43","75","","","Percent of Total Billed Charges","neg_dollar:$2.43","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.85;103.5% of Medicaid interim rate","3.25","150","","","Percent of Total Billed Charges","neg_dollar:$5.02;150% of Medicaid interim rate","2.60","80","","","Percent of Total Billed Charges","neg_dollar:$2.60;Percent of Total Billed Charges","2.99","92","","","Percent of Total Billed Charges","neg_dollar:$2.99","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"DICLOFENAC SODIUM 75 MG PO TBEC","A9270","HCPCS","68001-281-06","NDC","637","RC","","Facility","Outpatient","1","EA","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","101% of Medicare Fee Schedule","","","","1.35","Fee Schedule","","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LEVOTHYROXINE SODIUM 75 MCG PO TABS","A9270","HCPCS","51079-441-01","NDC","637","RC","","Facility","Outpatient","1","EA","1.32","1.32","","","","1.32","Fee Schedule","","","","","1.32","Fee Schedule","101% of Medicare Fee Schedule","","","","1.32","Fee Schedule","","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.13","86","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","70","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% of Medicaid interim rate","0.99","75","","","Percent of Total Billed Charges","neg_dollar:$0.99","1.13","86","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","70","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.75;103.5% of Medicaid interim rate","1.32","150","","","Percent of Total Billed Charges","neg_dollar:$2.04;150% of Medicaid interim rate","1.05","80","","","Percent of Total Billed Charges","neg_dollar:$1.05;Percent of Total Billed Charges","1.21","92","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","52","","","Percent of Total Billed Charges","neg_dollar:$0.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS","A9270","HCPCS","68180-677-11","NDC","637","RC","","Facility","Outpatient","1","EA","4.15","4.15","","","","4.15","Fee Schedule","","","","","4.15","Fee Schedule","101% of Medicare Fee Schedule","","","","4.15","Fee Schedule","","2.15","52","","","Percent of Total Billed Charges","neg_dollar:$2.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.56","86","","","Percent of Total Billed Charges","neg_dollar:$3.56","2.90","70","","","Percent of Total Billed Charges","neg_dollar:$2.90","2.15","52","","","Percent of Total Billed Charges","neg_dollar:$2.15;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.43;102% of Medicaid interim rate","3.11","75","","","Percent of Total Billed Charges","neg_dollar:$3.11","3.56","86","","","Percent of Total Billed Charges","neg_dollar:$3.56","2.90","70","","","Percent of Total Billed Charges","neg_dollar:$2.90","2.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.36;103.5% of Medicaid interim rate","4.15","150","","","Percent of Total Billed Charges","neg_dollar:$6.41;150% of Medicaid interim rate","3.32","80","","","Percent of Total Billed Charges","neg_dollar:$3.32;Percent of Total Billed Charges","3.81","92","","","Percent of Total Billed Charges","neg_dollar:$3.81","2.15","52","","","Percent of Total Billed Charges","neg_dollar:$2.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.15","52","","","Percent of Total Billed Charges","neg_dollar:$2.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"VENLAFAXINE HCL ER 75 MG PO CP24","A9270","HCPCS","68084-709-11","NDC","637","RC","","Facility","Outpatient","1","EA","1.38","1.38","","","","1.38","Fee Schedule","","","","","1.38","Fee Schedule","101% of Medicare Fee Schedule","","","","1.38","Fee Schedule","","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.19","86","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","70","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.81;102% of Medicaid interim rate","1.03","75","","","Percent of Total Billed Charges","neg_dollar:$1.03","1.19","86","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","70","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.78;103.5% of Medicaid interim rate","1.38","150","","","Percent of Total Billed Charges","neg_dollar:$2.14;150% of Medicaid interim rate","1.10","80","","","Percent of Total Billed Charges","neg_dollar:$1.10;Percent of Total Billed Charges","1.27","92","","","Percent of Total Billed Charges","neg_dollar:$1.27","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS","A9270","HCPCS","64380-799-01","NDC","250","RC","","Facility","Outpatient","1","EA","3.25","3.25","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","","","52","","3.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","","52","","3.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.90;102% of Medicaid interim rate","2.43","75","","","Percent of Total Billed Charges","neg_dollar:$2.43","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.85;103.5% of Medicaid interim rate","3.25","150","","","Percent of Total Billed Charges","neg_dollar:$5.02;150% of Medicaid interim rate","2.60","80","","","Percent of Total Billed Charges","neg_dollar:$2.60;Percent of Total Billed Charges","2.99","92","","","Percent of Total Billed Charges","neg_dollar:$2.99","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.25","Fee Schedule","","1.00","3.00",""
"LEVOTHYROXINE SODIUM 75 MCG PO TABS","A9270","HCPCS","60687-475-11","NDC","637","RC","","Facility","Outpatient","1","EA","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","101% of Medicare Fee Schedule","","","","1.35","Fee Schedule","","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.77;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.09;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SENNOSIDES 8.6 MG PO TABS","A9270","HCPCS","00904-7252-61","NDC","250","RC","","Facility","Outpatient","1","ME","0.81","0.81","","","","0.81","Fee Schedule","","","","","0.81","Fee Schedule","","","","","0.81","Fee Schedule","","","52","","0.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","86","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","70","","","Percent of Total Billed Charges","neg_dollar:$0.56","","52","","0.81","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% of Medicaid interim rate","0.60","75","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.69","86","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","70","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;103.5% of Medicaid interim rate","0.81","150","","","Percent of Total Billed Charges","neg_dollar:$1.25;150% of Medicaid interim rate","0.64","80","","","Percent of Total Billed Charges","neg_dollar:$0.64;Percent of Total Billed Charges","0.74","92","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.81","Fee Schedule","","1.00","1.00",""
"SENNOSIDES 8.6 MG PO TABS","A9270","HCPCS","00904-6522-61","NDC","250","RC","","Facility","Outpatient","1","ME","1.12","1.12","","","","1.12","Fee Schedule","","","","","1.12","Fee Schedule","","","","","1.12","Fee Schedule","","","52","","1.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","","52","","1.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% of Medicaid interim rate","0.84","75","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;103.5% of Medicaid interim rate","1.12","150","","","Percent of Total Billed Charges","neg_dollar:$1.73;150% of Medicaid interim rate","0.89","80","","","Percent of Total Billed Charges","neg_dollar:$0.89;Percent of Total Billed Charges","1.03","92","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.12","Fee Schedule","","1.00","1.00",""
"SENNOSIDES 8.6 MG PO TABS","A9270","HCPCS","00904-7252-61","NDC","637","RC","","Facility","Outpatient","1","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","101% of Medicare Fee Schedule","","","","1.05","Fee Schedule","","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SENNOSIDES 8.6 MG PO TABS","A9270","HCPCS","00904-6522-61","NDC","637","RC","","Facility","Outpatient","1","ME","0.55","0.55","","","","0.55","Fee Schedule","","","","","0.55","Fee Schedule","101% of Medicare Fee Schedule","","","","0.55","Fee Schedule","","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% of Medicaid interim rate","0.41","75","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.31;103.5% of Medicaid interim rate","0.55","150","","","Percent of Total Billed Charges","neg_dollar:$0.85;150% of Medicaid interim rate","0.44","80","","","Percent of Total Billed Charges","neg_dollar:$0.44;Percent of Total Billed Charges","0.50","92","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SENNOSIDES 8.6 MG PO TABS","A9270","HCPCS","71399-8245-3","NDC","250","RC","","Facility","Outpatient","1","ME","0.70","0.70","","","","0.70","Fee Schedule","","","","","0.70","Fee Schedule","","","","","0.70","Fee Schedule","","","52","","0.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","52","","","Percent of Total Billed Charges","neg_dollar:$0.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","52","","","Percent of Total Billed Charges","neg_dollar:$0.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","86","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.49","70","","","Percent of Total Billed Charges","neg_dollar:$0.49","","52","","0.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% of Medicaid interim rate","0.52","75","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.60","86","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.49","70","","","Percent of Total Billed Charges","neg_dollar:$0.49","0.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.40;103.5% of Medicaid interim rate","0.70","150","","","Percent of Total Billed Charges","neg_dollar:$1.08;150% of Medicaid interim rate","0.56","80","","","Percent of Total Billed Charges","neg_dollar:$0.56;Percent of Total Billed Charges","0.64","92","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.36","52","","","Percent of Total Billed Charges","neg_dollar:$0.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.70","Fee Schedule","","1.00","1.00",""
"SENNOSIDES 8.6 MG PO TABS","A9270","HCPCS","71399-8245-3","NDC","637","RC","","Facility","Outpatient","1","ME","0.59","0.59","","","","0.59","Fee Schedule","","","","","0.59","Fee Schedule","101% of Medicare Fee Schedule","","","","0.59","Fee Schedule","","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.59","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.59","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.41","70","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.34;102% of Medicaid interim rate","0.44","75","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.41","70","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.33;103.5% of Medicaid interim rate","0.59","150","","","Percent of Total Billed Charges","neg_dollar:$0.92;150% of Medicaid interim rate","0.47","80","","","Percent of Total Billed Charges","neg_dollar:$0.47;Percent of Total Billed Charges","0.54","92","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.30","52","","","Percent of Total Billed Charges","neg_dollar:$0.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG PO TABS","A9270","HCPCS","00536-1248-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG PO TABS","A9270","HCPCS","60687-622-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.04","1.04","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","52","","1.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.04","150","","","Percent of Total Billed Charges","neg_dollar:$1.61;150% of Medicaid interim rate","0.83","80","","","Percent of Total Billed Charges","neg_dollar:$0.83;Percent of Total Billed Charges","0.95","92","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.04","Fee Schedule","","1.00","1.00",""
"SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG PO TABS","A9270","HCPCS","60687-622-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG PO TABS","A9270","HCPCS","60687-622-01","NDC","637","RC","","Facility","Outpatient","1","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG PO TABS","A9270","HCPCS","60687-622-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.06","1.06","","","","1.06","Fee Schedule","","","","","1.06","Fee Schedule","101% of Medicare Fee Schedule","","","","1.06","Fee Schedule","","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","86","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.74","70","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% of Medicaid interim rate","0.79","75","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.91","86","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.74","70","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;103.5% of Medicaid interim rate","1.06","150","","","Percent of Total Billed Charges","neg_dollar:$1.64;150% of Medicaid interim rate","0.85","80","","","Percent of Total Billed Charges","neg_dollar:$0.85;Percent of Total Billed Charges","0.97","92","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PROPRANOLOL HCL ER 80 MG PO CP24","A9270","HCPCS","60687-226-11","NDC","250","RC","","Facility","Outpatient","80","ME","3.80","3.80","","","","3.80","Fee Schedule","","","","","3.80","Fee Schedule","","","","","3.80","Fee Schedule","","","52","","3.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.97","52","","","Percent of Total Billed Charges","neg_dollar:$1.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.97","52","","","Percent of Total Billed Charges","neg_dollar:$1.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.26","86","","","Percent of Total Billed Charges","neg_dollar:$3.26","2.65","70","","","Percent of Total Billed Charges","neg_dollar:$2.65","","52","","3.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.23;102% of Medicaid interim rate","2.84","75","","","Percent of Total Billed Charges","neg_dollar:$2.84","3.26","86","","","Percent of Total Billed Charges","neg_dollar:$3.26","2.65","70","","","Percent of Total Billed Charges","neg_dollar:$2.65","2.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.16;103.5% of Medicaid interim rate","3.80","150","","","Percent of Total Billed Charges","neg_dollar:$5.87;150% of Medicaid interim rate","3.04","80","","","Percent of Total Billed Charges","neg_dollar:$3.04;Percent of Total Billed Charges","3.49","92","","","Percent of Total Billed Charges","neg_dollar:$3.49","1.97","52","","","Percent of Total Billed Charges","neg_dollar:$1.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.80","Fee Schedule","","1.00","3.00",""
"SIMETHICONE 80 MG PO CHEW","A9270","HCPCS","77333-812-10","NDC","250","RC","","Facility","Outpatient","80","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"SIMETHICONE 80 MG PO CHEW","A9270","HCPCS","77333-812-25","NDC","250","RC","","Facility","Outpatient","80","ME","1.23","1.23","","","","1.23","Fee Schedule","","","","","1.23","Fee Schedule","","","","","1.23","Fee Schedule","","","52","","1.23","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","52","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","52","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","86","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.86","70","","","Percent of Total Billed Charges","neg_dollar:$0.86","","52","","1.23","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% of Medicaid interim rate","0.92","75","","","Percent of Total Billed Charges","neg_dollar:$0.92","1.06","86","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.86","70","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;103.5% of Medicaid interim rate","1.23","150","","","Percent of Total Billed Charges","neg_dollar:$1.91;150% of Medicaid interim rate","0.99","80","","","Percent of Total Billed Charges","neg_dollar:$0.99;Percent of Total Billed Charges","1.14","92","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.64","52","","","Percent of Total Billed Charges","neg_dollar:$0.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.23","Fee Schedule","","1.00","1.00",""
"PROPRANOLOL HCL ER 80 MG PO CP24","A9270","HCPCS","60687-226-11","NDC","637","RC","","Facility","Outpatient","80","ME","3.80","3.80","","","","3.80","Fee Schedule","","","","","3.80","Fee Schedule","101% of Medicare Fee Schedule","","","","3.80","Fee Schedule","","1.97","52","","","Percent of Total Billed Charges","neg_dollar:$1.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.26","86","","","Percent of Total Billed Charges","neg_dollar:$3.26","2.65","70","","","Percent of Total Billed Charges","neg_dollar:$2.65","1.97","52","","","Percent of Total Billed Charges","neg_dollar:$1.97;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.23;102% of Medicaid interim rate","2.84","75","","","Percent of Total Billed Charges","neg_dollar:$2.84","3.26","86","","","Percent of Total Billed Charges","neg_dollar:$3.26","2.65","70","","","Percent of Total Billed Charges","neg_dollar:$2.65","2.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.16;103.5% of Medicaid interim rate","3.80","150","","","Percent of Total Billed Charges","neg_dollar:$5.87;150% of Medicaid interim rate","3.04","80","","","Percent of Total Billed Charges","neg_dollar:$3.04;Percent of Total Billed Charges","3.49","92","","","Percent of Total Billed Charges","neg_dollar:$3.49","1.97","52","","","Percent of Total Billed Charges","neg_dollar:$1.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.97","52","","","Percent of Total Billed Charges","neg_dollar:$1.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"SIMETHICONE 80 MG PO CHEW","A9270","HCPCS","77333-812-25","NDC","637","RC","","Facility","Outpatient","80","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS","A9270","HCPCS","60687-614-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS","A9270","HCPCS","60687-614-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","101% of Medicare Fee Schedule","","","","1.35","Fee Schedule","","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TAKE HOME BACTRIM DS PO TABS (QTY:FOUR)","A9270","HCPCS","53746-271-01","NDC","253","RC","","Facility","Outpatient","1","ME","11.40","11.40","11.40","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","11.40","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.80","86","","","Percent of Total Billed Charges","neg_dollar:$9.80","7.97","70","","","Percent of Total Billed Charges","neg_dollar:$7.97","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.69;102% of Medicaid interim rate","8.55","75","","","Percent of Total Billed Charges","neg_dollar:$8.55","9.80","86","","","Percent of Total Billed Charges","neg_dollar:$9.80","7.97","70","","","Percent of Total Billed Charges","neg_dollar:$7.97","6.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.49;103.5% of Medicaid interim rate","11.40","150","","","Percent of Total Billed Charges","neg_dollar:$17.62;150% of Medicaid interim rate","9.12","80","","","Percent of Total Billed Charges","neg_dollar:$9.12;Percent of Total Billed Charges","10.48","92","","","Percent of Total Billed Charges","neg_dollar:$10.48","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","11.00",""
"TAKE HOME BACTRIM DS PO TABS (QTY:FOUR)","A9270","HCPCS","53746-271-01","NDC","250","RC","","Facility","Outpatient","1","ME","11.40","11.40","","","","11.40","Fee Schedule","","","","","11.40","Fee Schedule","","","","","11.40","Fee Schedule","","","52","","11.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.80","86","","","Percent of Total Billed Charges","neg_dollar:$9.80","7.97","70","","","Percent of Total Billed Charges","neg_dollar:$7.97","","52","","11.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.69;102% of Medicaid interim rate","8.55","75","","","Percent of Total Billed Charges","neg_dollar:$8.55","9.80","86","","","Percent of Total Billed Charges","neg_dollar:$9.80","7.97","70","","","Percent of Total Billed Charges","neg_dollar:$7.97","6.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.49;103.5% of Medicaid interim rate","11.40","150","","","Percent of Total Billed Charges","neg_dollar:$17.62;150% of Medicaid interim rate","9.12","80","","","Percent of Total Billed Charges","neg_dollar:$9.12;Percent of Total Billed Charges","10.48","92","","","Percent of Total Billed Charges","neg_dollar:$10.48","5.92","52","","","Percent of Total Billed Charges","neg_dollar:$5.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","11.40","Fee Schedule","","5.00","11.00",""
"ASPIRIN LOW DOSE 81 MG PO CHEW","A9270","HCPCS","00904-6794-89","NDC","250","RC","","Facility","Outpatient","81","ME","0.12","0.12","","","","0.12","Fee Schedule","","","","","0.12","Fee Schedule","","","","","0.12","Fee Schedule","","","52","","0.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.10","86","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.08","70","","","Percent of Total Billed Charges","neg_dollar:$0.08","","52","","0.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.07;102% of Medicaid interim rate","0.09","75","","","Percent of Total Billed Charges","neg_dollar:$0.09","0.10","86","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.08","70","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.07;103.5% of Medicaid interim rate","0.12","150","","","Percent of Total Billed Charges","neg_dollar:$0.19;150% of Medicaid interim rate","0.10","80","","","Percent of Total Billed Charges","neg_dollar:$0.10;Percent of Total Billed Charges","0.11","92","","","Percent of Total Billed Charges","neg_dollar:$0.11","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.12","Fee Schedule","","1.00","1.00",""
"ASPIRIN 81 MG PO TBEC","A9270","HCPCS","63739-212-02","NDC","250","RC","","Facility","Outpatient","81","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","","52","","0.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.50","Fee Schedule","","1.00","1.00",""
"ASPIRIN 81 MG PO TBEC","A9270","HCPCS","00904-6783-70","NDC","250","RC","","Facility","Outpatient","81","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","","52","","0.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.50","Fee Schedule","","1.00","1.00",""
"ASPIRIN LOW DOSE 81 MG PO CHEW","A9270","HCPCS","00904-6794-89","NDC","637","RC","","Facility","Outpatient","81","ME","0.12","0.12","","","","0.12","Fee Schedule","","","","","0.12","Fee Schedule","101% of Medicare Fee Schedule","","","","0.12","Fee Schedule","","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.10","86","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.08","70","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.07;102% of Medicaid interim rate","0.09","75","","","Percent of Total Billed Charges","neg_dollar:$0.09","0.10","86","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.08","70","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.07;103.5% of Medicaid interim rate","0.12","150","","","Percent of Total Billed Charges","neg_dollar:$0.19;150% of Medicaid interim rate","0.10","80","","","Percent of Total Billed Charges","neg_dollar:$0.10;Percent of Total Billed Charges","0.11","92","","","Percent of Total Billed Charges","neg_dollar:$0.11","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ASPIRIN 81 MG PO TBEC","A9270","HCPCS","63739-212-02","NDC","637","RC","","Facility","Outpatient","81","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","101% of Medicare Fee Schedule","","","","0.50","Fee Schedule","","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ASPIRIN 81 MG PO TBEC","A9270","HCPCS","00904-6783-70","NDC","637","RC","","Facility","Outpatient","81","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","101% of Medicare Fee Schedule","","","","0.50","Fee Schedule","","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ASPIRIN LOW DOSE 81 MG PO CHEW","A9270","HCPCS","63739-434-02","NDC","637","RC","","Facility","Outpatient","81","ME","0.18","0.18","","","","0.18","Fee Schedule","","","","","0.18","Fee Schedule","101% of Medicare Fee Schedule","","","","0.18","Fee Schedule","","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.16","86","","","Percent of Total Billed Charges","neg_dollar:$0.16","0.13","70","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.11;102% of Medicaid interim rate","0.14","75","","","Percent of Total Billed Charges","neg_dollar:$0.14","0.16","86","","","Percent of Total Billed Charges","neg_dollar:$0.16","0.13","70","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.10;103.5% of Medicaid interim rate","0.18","150","","","Percent of Total Billed Charges","neg_dollar:$0.29;150% of Medicaid interim rate","0.15","80","","","Percent of Total Billed Charges","neg_dollar:$0.15;Percent of Total Billed Charges","0.17","92","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ASPIRIN LOW DOSE 81 MG PO CHEW","A9270","HCPCS","63739-434-02","NDC","250","RC","","Facility","Outpatient","1","EA","0.30","0.30","","","","0.30","Fee Schedule","","","","","0.30","Fee Schedule","","","","","0.30","Fee Schedule","","","52","","0.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.15","52","","","Percent of Total Billed Charges","neg_dollar:$0.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.15","52","","","Percent of Total Billed Charges","neg_dollar:$0.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","86","","","Percent of Total Billed Charges","neg_dollar:$0.26","0.21","70","","","Percent of Total Billed Charges","neg_dollar:$0.21","","52","","0.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.18;102% of Medicaid interim rate","0.22","75","","","Percent of Total Billed Charges","neg_dollar:$0.22","0.26","86","","","Percent of Total Billed Charges","neg_dollar:$0.26","0.21","70","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.17;103.5% of Medicaid interim rate","0.30","150","","","Percent of Total Billed Charges","neg_dollar:$0.47;150% of Medicaid interim rate","0.24","80","","","Percent of Total Billed Charges","neg_dollar:$0.24;Percent of Total Billed Charges","0.28","92","","","Percent of Total Billed Charges","neg_dollar:$0.28","0.15","52","","","Percent of Total Billed Charges","neg_dollar:$0.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.30","Fee Schedule","","1.00","1.00",""
"METFORMIN HCL 850 MG PO TABS","A9270","HCPCS","60687-143-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","A9270","HCPCS","60687-803-11","NDC","250","RC","","Facility","Outpatient","1","EA","8.65","8.65","","","","8.65","Fee Schedule","","","","","8.65","Fee Schedule","","","","","8.65","Fee Schedule","","","52","","8.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.49","52","","","Percent of Total Billed Charges","neg_dollar:$4.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.49","52","","","Percent of Total Billed Charges","neg_dollar:$4.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.43","86","","","Percent of Total Billed Charges","neg_dollar:$7.43","6.05","70","","","Percent of Total Billed Charges","neg_dollar:$6.05","","52","","8.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.08;102% of Medicaid interim rate","6.48","75","","","Percent of Total Billed Charges","neg_dollar:$6.48","7.43","86","","","Percent of Total Billed Charges","neg_dollar:$7.43","6.05","70","","","Percent of Total Billed Charges","neg_dollar:$6.05","4.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.93;103.5% of Medicaid interim rate","8.65","150","","","Percent of Total Billed Charges","neg_dollar:$13.37;150% of Medicaid interim rate","6.92","80","","","Percent of Total Billed Charges","neg_dollar:$6.92;Percent of Total Billed Charges","7.95","92","","","Percent of Total Billed Charges","neg_dollar:$7.95","4.49","52","","","Percent of Total Billed Charges","neg_dollar:$4.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","8.65","Fee Schedule","","4.00","8.00",""
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","A9270","HCPCS","65862-503-20","NDC","250","RC","","Facility","Outpatient","1","EA","1.79","1.79","","","","1.79","Fee Schedule","","","","","1.79","Fee Schedule","","","","","1.79","Fee Schedule","","","52","","1.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.53","86","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.25","70","","","Percent of Total Billed Charges","neg_dollar:$1.25","","52","","1.79","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;102% of Medicaid interim rate","1.34","75","","","Percent of Total Billed Charges","neg_dollar:$1.34","1.53","86","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.25","70","","","Percent of Total Billed Charges","neg_dollar:$1.25","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;103.5% of Medicaid interim rate","1.79","150","","","Percent of Total Billed Charges","neg_dollar:$2.76;150% of Medicaid interim rate","1.43","80","","","Percent of Total Billed Charges","neg_dollar:$1.43;Percent of Total Billed Charges","1.64","92","","","Percent of Total Billed Charges","neg_dollar:$1.64","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.79","Fee Schedule","","1.00","1.00",""
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","A9270","HCPCS","60687-803-11","NDC","637","RC","","Facility","Outpatient","1","EA","8.65","8.65","","","","8.65","Fee Schedule","","","","","8.65","Fee Schedule","101% of Medicare Fee Schedule","","","","8.65","Fee Schedule","","4.49","52","","","Percent of Total Billed Charges","neg_dollar:$4.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.43","86","","","Percent of Total Billed Charges","neg_dollar:$7.43","6.05","70","","","Percent of Total Billed Charges","neg_dollar:$6.05","4.49","52","","","Percent of Total Billed Charges","neg_dollar:$4.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.08;102% of Medicaid interim rate","6.48","75","","","Percent of Total Billed Charges","neg_dollar:$6.48","7.43","86","","","Percent of Total Billed Charges","neg_dollar:$7.43","6.05","70","","","Percent of Total Billed Charges","neg_dollar:$6.05","4.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.93;103.5% of Medicaid interim rate","8.65","150","","","Percent of Total Billed Charges","neg_dollar:$13.37;150% of Medicaid interim rate","6.92","80","","","Percent of Total Billed Charges","neg_dollar:$6.92;Percent of Total Billed Charges","7.95","92","","","Percent of Total Billed Charges","neg_dollar:$7.95","4.49","52","","","Percent of Total Billed Charges","neg_dollar:$4.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.49","52","","","Percent of Total Billed Charges","neg_dollar:$4.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","8.00",""
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","A9270","HCPCS","65862-503-20","NDC","637","RC","","Facility","Outpatient","1","EA","2.25","2.25","","","","2.25","Fee Schedule","","","","","2.25","Fee Schedule","101% of Medicare Fee Schedule","","","","2.25","Fee Schedule","","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.94","86","","","Percent of Total Billed Charges","neg_dollar:$1.94","1.58","70","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% of Medicaid interim rate","1.69","75","","","Percent of Total Billed Charges","neg_dollar:$1.69","1.94","86","","","Percent of Total Billed Charges","neg_dollar:$1.94","1.58","70","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.28;103.5% of Medicaid interim rate","2.25","150","","","Percent of Total Billed Charges","neg_dollar:$3.49;150% of Medicaid interim rate","1.80","80","","","Percent of Total Billed Charges","neg_dollar:$1.80;Percent of Total Billed Charges","2.07","92","","","Percent of Total Billed Charges","neg_dollar:$2.07","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"TAKE HOME AUGMENTIN 875MG TABS (QTY:FOUR)","A9270","HCPCS","66685-1001-0","NDC","253","RC","","Facility","Outpatient","1","EA","15.70","15.70","15.70","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","15.70","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.50","86","","","Percent of Total Billed Charges","neg_dollar:$13.50","10.98","70","","","Percent of Total Billed Charges","neg_dollar:$10.98","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.22;102% of Medicaid interim rate","11.77","75","","","Percent of Total Billed Charges","neg_dollar:$11.77","13.50","86","","","Percent of Total Billed Charges","neg_dollar:$13.50","10.98","70","","","Percent of Total Billed Charges","neg_dollar:$10.98","8.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.94;103.5% of Medicaid interim rate","15.70","150","","","Percent of Total Billed Charges","neg_dollar:$24.27;150% of Medicaid interim rate","12.56","80","","","Percent of Total Billed Charges","neg_dollar:$12.56;Percent of Total Billed Charges","14.44","92","","","Percent of Total Billed Charges","neg_dollar:$14.44","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","15.00",""
"TAKE HOME AUGMENTIN 875MG TABS (QTY:FOUR)","A9270","HCPCS","66685-1001-0","NDC","250","RC","","Facility","Outpatient","1","EA","15.70","15.70","","","","15.70","Fee Schedule","","","","","15.70","Fee Schedule","","","","","15.70","Fee Schedule","","","52","","15.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.50","86","","","Percent of Total Billed Charges","neg_dollar:$13.50","10.98","70","","","Percent of Total Billed Charges","neg_dollar:$10.98","","52","","15.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.22;102% of Medicaid interim rate","11.77","75","","","Percent of Total Billed Charges","neg_dollar:$11.77","13.50","86","","","Percent of Total Billed Charges","neg_dollar:$13.50","10.98","70","","","Percent of Total Billed Charges","neg_dollar:$10.98","8.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.94;103.5% of Medicaid interim rate","15.70","150","","","Percent of Total Billed Charges","neg_dollar:$24.27;150% of Medicaid interim rate","12.56","80","","","Percent of Total Billed Charges","neg_dollar:$12.56;Percent of Total Billed Charges","14.44","92","","","Percent of Total Billed Charges","neg_dollar:$14.44","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","15.70","Fee Schedule","","8.00","15.00",""
"LEVOTHYROXINE SODIUM 88 MCG PO TABS","A9270","HCPCS","60687-486-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","","52","","1.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.70","Fee Schedule","","1.00","1.00",""
"LEVOTHYROXINE SODIUM 88 MCG PO TABS","A9270","HCPCS","60687-486-11","NDC","637","RC","","Facility","Outpatient","1","EA","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","101% of Medicare Fee Schedule","","","","1.70","Fee Schedule","","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TICAGRELOR 90 MG PO TABS","A9270","HCPCS","00186-0777-60","NDC","250","RC","","Facility","Outpatient","1","EA","9.80","9.80","","","","9.80","Fee Schedule","","","","","9.80","Fee Schedule","","","","","9.80","Fee Schedule","","","52","","9.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.09","52","","","Percent of Total Billed Charges","neg_dollar:$5.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.09","52","","","Percent of Total Billed Charges","neg_dollar:$5.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.42","86","","","Percent of Total Billed Charges","neg_dollar:$8.42","6.86","70","","","Percent of Total Billed Charges","neg_dollar:$6.86","","52","","9.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.75;102% of Medicaid interim rate","7.35","75","","","Percent of Total Billed Charges","neg_dollar:$7.35","8.42","86","","","Percent of Total Billed Charges","neg_dollar:$8.42","6.86","70","","","Percent of Total Billed Charges","neg_dollar:$6.86","5.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.58;103.5% of Medicaid interim rate","9.80","150","","","Percent of Total Billed Charges","neg_dollar:$15.15;150% of Medicaid interim rate","7.84","80","","","Percent of Total Billed Charges","neg_dollar:$7.84;Percent of Total Billed Charges","9.01","92","","","Percent of Total Billed Charges","neg_dollar:$9.01","5.09","52","","","Percent of Total Billed Charges","neg_dollar:$5.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","9.80","Fee Schedule","","5.00","9.00",""
"TICAGRELOR 90 MG PO TABS","A9270","HCPCS","00186-0777-60","NDC","637","RC","","Facility","Outpatient","1","EA","10.05","10.05","","","","10.05","Fee Schedule","","","","","10.05","Fee Schedule","101% of Medicare Fee Schedule","","","","10.05","Fee Schedule","","5.22","52","","","Percent of Total Billed Charges","neg_dollar:$5.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.64","86","","","Percent of Total Billed Charges","neg_dollar:$8.64","7.03","70","","","Percent of Total Billed Charges","neg_dollar:$7.03","5.22","52","","","Percent of Total Billed Charges","neg_dollar:$5.22;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.90;102% of Medicaid interim rate","7.53","75","","","Percent of Total Billed Charges","neg_dollar:$7.53","8.64","86","","","Percent of Total Billed Charges","neg_dollar:$8.64","7.03","70","","","Percent of Total Billed Charges","neg_dollar:$7.03","5.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.72;103.5% of Medicaid interim rate","10.05","150","","","Percent of Total Billed Charges","neg_dollar:$15.53;150% of Medicaid interim rate","8.04","80","","","Percent of Total Billed Charges","neg_dollar:$8.04;Percent of Total Billed Charges","9.24","92","","","Percent of Total Billed Charges","neg_dollar:$9.24","5.22","52","","","Percent of Total Billed Charges","neg_dollar:$5.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.22","52","","","Percent of Total Billed Charges","neg_dollar:$5.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"PRESERVISION AREDS PO TABS","A9270","HCPCS","24208-432-62","NDC","250","RC","","Facility","Outpatient","1","EA","0.65","0.65","","","","0.65","Fee Schedule","","","","","0.65","Fee Schedule","","","","","0.65","Fee Schedule","","","52","","0.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","","52","","0.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.38;102% of Medicaid interim rate","0.48","75","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","0.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.37;103.5% of Medicaid interim rate","0.65","150","","","Percent of Total Billed Charges","neg_dollar:$1;150% of Medicaid interim rate","0.52","80","","","Percent of Total Billed Charges","neg_dollar:$0.52;Percent of Total Billed Charges","0.59","92","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.65","Fee Schedule","","1.00","1.00",""
"ARTIFICIAL TEARS OINTMENT WRAPPER","A9270","HCPCS","00065-0518-01","NDC","250","RC","","Facility","Outpatient","1","EA","18.40","18.40","","","","18.40","Fee Schedule","","","","","18.40","Fee Schedule","","","","","18.40","Fee Schedule","","","52","","18.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.56","52","","","Percent of Total Billed Charges","neg_dollar:$9.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.56","52","","","Percent of Total Billed Charges","neg_dollar:$9.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.82","86","","","Percent of Total Billed Charges","neg_dollar:$15.82","12.87","70","","","Percent of Total Billed Charges","neg_dollar:$12.87","","52","","18.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.80;102% of Medicaid interim rate","13.79","75","","","Percent of Total Billed Charges","neg_dollar:$13.79","15.82","86","","","Percent of Total Billed Charges","neg_dollar:$15.82","12.87","70","","","Percent of Total Billed Charges","neg_dollar:$12.87","10.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.48;103.5% of Medicaid interim rate","18.40","150","","","Percent of Total Billed Charges","neg_dollar:$28.44;150% of Medicaid interim rate","14.71","80","","","Percent of Total Billed Charges","neg_dollar:$14.71;Percent of Total Billed Charges","16.92","92","","","Percent of Total Billed Charges","neg_dollar:$16.92","9.56","52","","","Percent of Total Billed Charges","neg_dollar:$9.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","18.40","Fee Schedule","","9.00","18.00",""
"ARTIFICIAL TEARS OP SOLN WRAPPER","A9270","HCPCS","50268-043-15","NDC","250","RC","","Facility","Outpatient","1","EA","17.40","17.40","","","","17.40","Fee Schedule","","","","","17.40","Fee Schedule","","","","","17.40","Fee Schedule","","","52","","17.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.04","52","","","Percent of Total Billed Charges","neg_dollar:$9.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.04","52","","","Percent of Total Billed Charges","neg_dollar:$9.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.96","86","","","Percent of Total Billed Charges","neg_dollar:$14.96","12.17","70","","","Percent of Total Billed Charges","neg_dollar:$12.17","","52","","17.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.22;102% of Medicaid interim rate","13.04","75","","","Percent of Total Billed Charges","neg_dollar:$13.04","14.96","86","","","Percent of Total Billed Charges","neg_dollar:$14.96","12.17","70","","","Percent of Total Billed Charges","neg_dollar:$12.17","9.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.91;103.5% of Medicaid interim rate","17.40","150","","","Percent of Total Billed Charges","neg_dollar:$26.90;150% of Medicaid interim rate","13.92","80","","","Percent of Total Billed Charges","neg_dollar:$13.92;Percent of Total Billed Charges","16.00","92","","","Percent of Total Billed Charges","neg_dollar:$16","9.04","52","","","Percent of Total Billed Charges","neg_dollar:$9.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","17.40","Fee Schedule","","9.00","17.00",""
"ARTIFICIAL TEARS OP SOLN WRAPPER","A9270","HCPCS","57896-184-05","NDC","250","RC","","Facility","Outpatient","1","EA","11.95","11.95","","","","11.95","Fee Schedule","","","","","11.95","Fee Schedule","","","","","11.95","Fee Schedule","","","52","","11.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","","52","","11.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.02;102% of Medicaid interim rate","8.96","75","","","Percent of Total Billed Charges","neg_dollar:$8.96","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.81;103.5% of Medicaid interim rate","11.95","150","","","Percent of Total Billed Charges","neg_dollar:$18.47;150% of Medicaid interim rate","9.56","80","","","Percent of Total Billed Charges","neg_dollar:$9.56;Percent of Total Billed Charges","10.99","92","","","Percent of Total Billed Charges","neg_dollar:$10.99","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","11.95","Fee Schedule","","6.00","11.00",""
"THERA PO TABS","A9270","HCPCS","00904-0530-61","NDC","250","RC","","Facility","Outpatient","1","EA","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"ARTIFICIAL TEARS OINTMENT WRAPPER","A9270","HCPCS","17478-062-35","NDC","250","RC","","Facility","Outpatient","1","EA","18.20","18.20","","","","18.20","Fee Schedule","","","","","18.20","Fee Schedule","","","","","18.20","Fee Schedule","","","52","","18.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.46","52","","","Percent of Total Billed Charges","neg_dollar:$9.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.46","52","","","Percent of Total Billed Charges","neg_dollar:$9.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.65","86","","","Percent of Total Billed Charges","neg_dollar:$15.65","12.73","70","","","Percent of Total Billed Charges","neg_dollar:$12.73","","52","","18.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.69;102% of Medicaid interim rate","13.64","75","","","Percent of Total Billed Charges","neg_dollar:$13.64","15.65","86","","","Percent of Total Billed Charges","neg_dollar:$15.65","12.73","70","","","Percent of Total Billed Charges","neg_dollar:$12.73","10.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.37;103.5% of Medicaid interim rate","18.20","150","","","Percent of Total Billed Charges","neg_dollar:$28.13;150% of Medicaid interim rate","14.56","80","","","Percent of Total Billed Charges","neg_dollar:$14.56;Percent of Total Billed Charges","16.74","92","","","Percent of Total Billed Charges","neg_dollar:$16.74","9.46","52","","","Percent of Total Billed Charges","neg_dollar:$9.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","18.20","Fee Schedule","","9.00","18.00",""
"HEALTHY EYES SUPERVISION 2 PO CAPS","A9270","HCPCS","24208-69760","NDC","637","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HEALTHY EYES SUPERVISION 2 PO CAPS","A9270","HCPCS","24208-69760","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"ARTIFICIAL TEARS OP SOLN WRAPPER","A9270","HCPCS","00536-1408-94","NDC","250","RC","","Facility","Outpatient","1","EA","16.40","16.40","","","","16.40","Fee Schedule","","","","","16.40","Fee Schedule","","","","","16.40","Fee Schedule","","","52","","16.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.10","86","","","Percent of Total Billed Charges","neg_dollar:$14.10","11.47","70","","","Percent of Total Billed Charges","neg_dollar:$11.47","","52","","16.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.63;102% of Medicaid interim rate","12.29","75","","","Percent of Total Billed Charges","neg_dollar:$12.29","14.10","86","","","Percent of Total Billed Charges","neg_dollar:$14.10","11.47","70","","","Percent of Total Billed Charges","neg_dollar:$11.47","9.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.34;103.5% of Medicaid interim rate","16.40","150","","","Percent of Total Billed Charges","neg_dollar:$25.35;150% of Medicaid interim rate","13.12","80","","","Percent of Total Billed Charges","neg_dollar:$13.12;Percent of Total Billed Charges","15.08","92","","","Percent of Total Billed Charges","neg_dollar:$15.08","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","16.40","Fee Schedule","","8.00","16.00",""
"ARTIFICIAL TEARS OINTMENT WRAPPER","A9270","HCPCS","46122-757-37","NDC","250","RC","","Facility","Outpatient","1","EA","17.90","17.90","","","","17.90","Fee Schedule","","","","","17.90","Fee Schedule","","","","","17.90","Fee Schedule","","","52","","17.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.39","86","","","Percent of Total Billed Charges","neg_dollar:$15.39","12.52","70","","","Percent of Total Billed Charges","neg_dollar:$12.52","","52","","17.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.51;102% of Medicaid interim rate","13.42","75","","","Percent of Total Billed Charges","neg_dollar:$13.42","15.39","86","","","Percent of Total Billed Charges","neg_dollar:$15.39","12.52","70","","","Percent of Total Billed Charges","neg_dollar:$12.52","10.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.20;103.5% of Medicaid interim rate","17.90","150","","","Percent of Total Billed Charges","neg_dollar:$27.67;150% of Medicaid interim rate","14.32","80","","","Percent of Total Billed Charges","neg_dollar:$14.32;Percent of Total Billed Charges","16.46","92","","","Percent of Total Billed Charges","neg_dollar:$16.46","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","17.90","Fee Schedule","","9.00","17.00",""
"CULTURELLE PO CAPS","A9270","HCPCS","49100-38164","NDC","250","RC","","Facility","Outpatient","1","EA","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","","52","","1.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.70","Fee Schedule","","1.00","1.00",""
"ARTIFICIAL TEARS OP SOLN WRAPPER","A9270","HCPCS","57896-184-05","NDC","637","RC","","Facility","Outpatient","1","EA","11.95","11.95","","","","11.95","Fee Schedule","","","","","11.95","Fee Schedule","101% of Medicare Fee Schedule","","","","11.95","Fee Schedule","","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.02;102% of Medicaid interim rate","8.96","75","","","Percent of Total Billed Charges","neg_dollar:$8.96","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.81;103.5% of Medicaid interim rate","11.95","150","","","Percent of Total Billed Charges","neg_dollar:$18.47;150% of Medicaid interim rate","9.56","80","","","Percent of Total Billed Charges","neg_dollar:$9.56;Percent of Total Billed Charges","10.99","92","","","Percent of Total Billed Charges","neg_dollar:$10.99","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","11.00",""
"I-VITE PROTECT PO TABS","A9270","HCPCS","24208-432-62","NDC","637","RC","","Facility","Outpatient","1","EA","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","101% of Medicare Fee Schedule","","","","1.15","Fee Schedule","","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PRESERVISION AREDS PO TABS","A9270","HCPCS","24208-432-62","NDC","637","RC","","Facility","Outpatient","1","EA","0.81","0.81","","","","0.81","Fee Schedule","","","","","0.81","Fee Schedule","101% of Medicare Fee Schedule","","","","0.81","Fee Schedule","","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","86","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% of Medicaid interim rate","0.61","75","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.70","86","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;103.5% of Medicaid interim rate","0.81","150","","","Percent of Total Billed Charges","neg_dollar:$1.26;150% of Medicaid interim rate","0.65","80","","","Percent of Total Billed Charges","neg_dollar:$0.65;Percent of Total Billed Charges","0.75","92","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"THERA PO TABS","A9270","HCPCS","00904-0530-61","NDC","637","RC","","Facility","Outpatient","1","EA","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","101% of Medicare Fee Schedule","","","","1.05","Fee Schedule","","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ARTIFICIAL TEARS OINTMENT WRAPPER","A9270","HCPCS","17478-062-35","NDC","637","RC","","Facility","Outpatient","1","EA","18.20","18.20","","","","18.20","Fee Schedule","","","","","18.20","Fee Schedule","101% of Medicare Fee Schedule","","","","18.20","Fee Schedule","","9.46","52","","","Percent of Total Billed Charges","neg_dollar:$9.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","18.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","18.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.65","86","","","Percent of Total Billed Charges","neg_dollar:$15.65","12.73","70","","","Percent of Total Billed Charges","neg_dollar:$12.73","9.46","52","","","Percent of Total Billed Charges","neg_dollar:$9.46;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.69;102% of Medicaid interim rate","13.64","75","","","Percent of Total Billed Charges","neg_dollar:$13.64","15.65","86","","","Percent of Total Billed Charges","neg_dollar:$15.65","12.73","70","","","Percent of Total Billed Charges","neg_dollar:$12.73","10.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.37;103.5% of Medicaid interim rate","18.20","150","","","Percent of Total Billed Charges","neg_dollar:$28.13;150% of Medicaid interim rate","14.56","80","","","Percent of Total Billed Charges","neg_dollar:$14.56;Percent of Total Billed Charges","16.74","92","","","Percent of Total Billed Charges","neg_dollar:$16.74","9.46","52","","","Percent of Total Billed Charges","neg_dollar:$9.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.46","52","","","Percent of Total Billed Charges","neg_dollar:$9.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","18.00",""
"ARTIFICIAL TEARS OP SOLN WRAPPER","A9270","HCPCS","00536-1408-94","NDC","637","RC","","Facility","Outpatient","1","EA","16.40","16.40","","","","16.40","Fee Schedule","","","","","16.40","Fee Schedule","101% of Medicare Fee Schedule","","","","16.40","Fee Schedule","","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.10","86","","","Percent of Total Billed Charges","neg_dollar:$14.10","11.47","70","","","Percent of Total Billed Charges","neg_dollar:$11.47","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.63;102% of Medicaid interim rate","12.29","75","","","Percent of Total Billed Charges","neg_dollar:$12.29","14.10","86","","","Percent of Total Billed Charges","neg_dollar:$14.10","11.47","70","","","Percent of Total Billed Charges","neg_dollar:$11.47","9.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.34;103.5% of Medicaid interim rate","16.40","150","","","Percent of Total Billed Charges","neg_dollar:$25.35;150% of Medicaid interim rate","13.12","80","","","Percent of Total Billed Charges","neg_dollar:$13.12;Percent of Total Billed Charges","15.08","92","","","Percent of Total Billed Charges","neg_dollar:$15.08","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","16.00",""
"CULTURELLE PO CAPS","A9270","HCPCS","49100-38164","NDC","637","RC","","Facility","Outpatient","1","EA","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","101% of Medicare Fee Schedule","","","","1.70","Fee Schedule","","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TC99M SESTAMIBI PER STUDY DOSE","A9500","HCPCS","27002284","CDM","343","RC","","Facility","Outpatient","","","303","242.40","303.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","157.56","52","","","Percent of Total Billed Charges","neg_dollar:$157.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","303.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","157.56","52","","","Percent of Total Billed Charges","neg_dollar:$157.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","157.56","52","","","Percent of Total Billed Charges","neg_dollar:$157.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","157.56","52","","","Percent of Total Billed Charges","neg_dollar:$157.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","260.58","86","","","Percent of Total Billed Charges","neg_dollar:$260.58","212.10","70","","","Percent of Total Billed Charges","neg_dollar:$212.10","157.56","52","","","Percent of Total Billed Charges","neg_dollar:$157.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","178.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$178.01;102% of Medicaid interim rate","227.25","75","","","Percent of Total Billed Charges","neg_dollar:$227.25","260.58","86","","","Percent of Total Billed Charges","neg_dollar:$260.58","212.10","70","","","Percent of Total Billed Charges","neg_dollar:$212.10","172.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$172.70;103.5% of Medicaid interim rate","303.00","150","","","Percent of Total Billed Charges","neg_dollar:$468.45;150% of Medicaid interim rate","242.40","80","","","Percent of Total Billed Charges","neg_dollar:$242.40;Percent of Total Billed Charges","","","","303.00","Fee Schedule","","157.56","52","","","Percent of Total Billed Charges","neg_dollar:$157.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","157.56","52","","","Percent of Total Billed Charges","neg_dollar:$157.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","157.00","303.00",""
"TC99M MEDRONATE TO 30 MCI","A9503","HCPCS","27002286","CDM","343","RC","","Facility","Outpatient","","","139","111.20","139.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","139.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","119.53","86","","","Percent of Total Billed Charges","neg_dollar:$119.53","97.30","70","","","Percent of Total Billed Charges","neg_dollar:$97.30","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","81.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$81.66;102% of Medicaid interim rate","104.25","75","","","Percent of Total Billed Charges","neg_dollar:$104.25","119.53","86","","","Percent of Total Billed Charges","neg_dollar:$119.53","97.30","70","","","Percent of Total Billed Charges","neg_dollar:$97.30","79.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$79.22;103.5% of Medicaid interim rate","139.00","150","","","Percent of Total Billed Charges","neg_dollar:$214.90;150% of Medicaid interim rate","111.20","80","","","Percent of Total Billed Charges","neg_dollar:$111.20;Percent of Total Billed Charges","","","","139.00","Fee Schedule","","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","72.00","139.00",""
"TC99M PERTECHNETATE PER MCI","A9512","HCPCS","27002291","CDM","343","RC","","Facility","Outpatient","","","168","134.40","168.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","87.36","52","","","Percent of Total Billed Charges","neg_dollar:$87.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","168.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","87.36","52","","","Percent of Total Billed Charges","neg_dollar:$87.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","87.36","52","","","Percent of Total Billed Charges","neg_dollar:$87.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","87.36","52","","","Percent of Total Billed Charges","neg_dollar:$87.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","144.48","86","","","Percent of Total Billed Charges","neg_dollar:$144.48","117.60","70","","","Percent of Total Billed Charges","neg_dollar:$117.60","87.36","52","","","Percent of Total Billed Charges","neg_dollar:$87.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","98.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$98.69;102% of Medicaid interim rate","126.00","75","","","Percent of Total Billed Charges","neg_dollar:$126","144.48","86","","","Percent of Total Billed Charges","neg_dollar:$144.48","117.60","70","","","Percent of Total Billed Charges","neg_dollar:$117.60","95.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$95.75;103.5% of Medicaid interim rate","168.00","150","","","Percent of Total Billed Charges","neg_dollar:$259.73;150% of Medicaid interim rate","134.40","80","","","Percent of Total Billed Charges","neg_dollar:$134.40;Percent of Total Billed Charges","","","","168.00","Fee Schedule","","87.36","52","","","Percent of Total Billed Charges","neg_dollar:$87.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","87.36","52","","","Percent of Total Billed Charges","neg_dollar:$87.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","87.00","168.00",""
"IODINE I-123 SOD IODIDE PER 100 UCI TO 999 UCI","A9516","HCPCS","27002292","CDM","343","RC","","Facility","Outpatient","","","432","345.60","432.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","224.64","52","","","Percent of Total Billed Charges","neg_dollar:$224.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","432.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","224.64","52","","","Percent of Total Billed Charges","neg_dollar:$224.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","224.64","52","","","Percent of Total Billed Charges","neg_dollar:$224.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","224.64","52","","","Percent of Total Billed Charges","neg_dollar:$224.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","371.52","86","","","Percent of Total Billed Charges","neg_dollar:$371.52","302.40","70","","","Percent of Total Billed Charges","neg_dollar:$302.40","224.64","52","","","Percent of Total Billed Charges","neg_dollar:$224.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","253.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$253.79;102% of Medicaid interim rate","324.00","75","","","Percent of Total Billed Charges","neg_dollar:$324","371.52","86","","","Percent of Total Billed Charges","neg_dollar:$371.52","302.40","70","","","Percent of Total Billed Charges","neg_dollar:$302.40","246.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$246.23;103.5% of Medicaid interim rate","432.00","150","","","Percent of Total Billed Charges","neg_dollar:$667.89;150% of Medicaid interim rate","345.60","80","","","Percent of Total Billed Charges","neg_dollar:$345.60;Percent of Total Billed Charges","","","","432.00","Fee Schedule","","224.64","52","","","Percent of Total Billed Charges","neg_dollar:$224.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","224.64","52","","","Percent of Total Billed Charges","neg_dollar:$224.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","224.00","432.00",""
"TC99M MEBROFENIN TO 15 MCI","A9537","HCPCS","27002296","CDM","343","RC","","Facility","Outpatient","","","196","156.80","196.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","101.92","52","","","Percent of Total Billed Charges","neg_dollar:$101.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","196.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","101.92","52","","","Percent of Total Billed Charges","neg_dollar:$101.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","101.92","52","","","Percent of Total Billed Charges","neg_dollar:$101.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","101.92","52","","","Percent of Total Billed Charges","neg_dollar:$101.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","168.56","86","","","Percent of Total Billed Charges","neg_dollar:$168.56","137.20","70","","","Percent of Total Billed Charges","neg_dollar:$137.20","101.92","52","","","Percent of Total Billed Charges","neg_dollar:$101.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","115.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$115.14;102% of Medicaid interim rate","147.00","75","","","Percent of Total Billed Charges","neg_dollar:$147","168.56","86","","","Percent of Total Billed Charges","neg_dollar:$168.56","137.20","70","","","Percent of Total Billed Charges","neg_dollar:$137.20","111.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$111.71;103.5% of Medicaid interim rate","196.00","150","","","Percent of Total Billed Charges","neg_dollar:$303.02;150% of Medicaid interim rate","156.80","80","","","Percent of Total Billed Charges","neg_dollar:$156.80;Percent of Total Billed Charges","","","","98.00","Fee Schedule","","101.92","52","","","Percent of Total Billed Charges","neg_dollar:$101.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","101.92","52","","","Percent of Total Billed Charges","neg_dollar:$101.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","98.00","196.00",""
"TC99M PENTETATE TO 25 MCI","A9539","HCPCS","27002298","CDM","343","RC","","Facility","Outpatient","","","2","1.60","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","","","","2.00","Fee Schedule","","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"TC99M MAA TO 10 MCI","A9540","HCPCS","27002299","CDM","343","RC","","Facility","Outpatient","","","453","362.40","453.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","453.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","389.58","86","","","Percent of Total Billed Charges","neg_dollar:$389.58","317.09","70","","","Percent of Total Billed Charges","neg_dollar:$317.09","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","266.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$266.13;102% of Medicaid interim rate","339.75","75","","","Percent of Total Billed Charges","neg_dollar:$339.75","389.58","86","","","Percent of Total Billed Charges","neg_dollar:$389.58","317.09","70","","","Percent of Total Billed Charges","neg_dollar:$317.09","258.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$258.21;103.5% of Medicaid interim rate","453.00","150","","","Percent of Total Billed Charges","neg_dollar:$700.36;150% of Medicaid interim rate","362.40","80","","","Percent of Total Billed Charges","neg_dollar:$362.40;Percent of Total Billed Charges","","","","453.00","Fee Schedule","","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","235.56","52","","","Percent of Total Billed Charges","neg_dollar:$235.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","235.00","453.00",""
"TC99M SULFUR COLLOID TO 20 MCI","A9541","HCPCS","27002300","CDM","343","RC","","Facility","Outpatient","","","448","358.40","448.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","448.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","385.28","86","","","Percent of Total Billed Charges","neg_dollar:$385.28","313.59","70","","","Percent of Total Billed Charges","neg_dollar:$313.59","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","263.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$263.19;102% of Medicaid interim rate","336.00","75","","","Percent of Total Billed Charges","neg_dollar:$336","385.28","86","","","Percent of Total Billed Charges","neg_dollar:$385.28","313.59","70","","","Percent of Total Billed Charges","neg_dollar:$313.59","255.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$255.35;103.5% of Medicaid interim rate","448.00","150","","","Percent of Total Billed Charges","neg_dollar:$692.63;150% of Medicaid interim rate","358.40","80","","","Percent of Total Billed Charges","neg_dollar:$358.40;Percent of Total Billed Charges","","","","448.00","Fee Schedule","","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","232.96","52","","","Percent of Total Billed Charges","neg_dollar:$232.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","232.00","448.00",""
"TC99M LABELED RBC TO 30 MCI","A9560","HCPCS","27002309","CDM","343","RC","","Facility","Outpatient","","","221","176.80","221.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","114.92","52","","","Percent of Total Billed Charges","neg_dollar:$114.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","221.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","114.92","52","","","Percent of Total Billed Charges","neg_dollar:$114.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","114.92","52","","","Percent of Total Billed Charges","neg_dollar:$114.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","114.92","52","","","Percent of Total Billed Charges","neg_dollar:$114.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","190.06","86","","","Percent of Total Billed Charges","neg_dollar:$190.06","154.70","70","","","Percent of Total Billed Charges","neg_dollar:$154.70","114.92","52","","","Percent of Total Billed Charges","neg_dollar:$114.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","129.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$129.83;102% of Medicaid interim rate","165.75","75","","","Percent of Total Billed Charges","neg_dollar:$165.75","190.06","86","","","Percent of Total Billed Charges","neg_dollar:$190.06","154.70","70","","","Percent of Total Billed Charges","neg_dollar:$154.70","125.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$125.96;103.5% of Medicaid interim rate","221.00","150","","","Percent of Total Billed Charges","neg_dollar:$341.67;150% of Medicaid interim rate","176.80","80","","","Percent of Total Billed Charges","neg_dollar:$176.80;Percent of Total Billed Charges","","","","221.00","Fee Schedule","","114.92","52","","","Percent of Total Billed Charges","neg_dollar:$114.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","114.92","52","","","Percent of Total Billed Charges","neg_dollar:$114.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","114.00","221.00",""
"TC99M OXIDRONATE TO 30 MCI","A9561","HCPCS","27002310","CDM","343","RC","","Facility","Outpatient","","","139","111.20","139.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","139.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","119.53","86","","","Percent of Total Billed Charges","neg_dollar:$119.53","97.30","70","","","Percent of Total Billed Charges","neg_dollar:$97.30","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","81.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$81.66;102% of Medicaid interim rate","104.25","75","","","Percent of Total Billed Charges","neg_dollar:$104.25","119.53","86","","","Percent of Total Billed Charges","neg_dollar:$119.53","97.30","70","","","Percent of Total Billed Charges","neg_dollar:$97.30","79.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$79.22;103.5% of Medicaid interim rate","139.00","150","","","Percent of Total Billed Charges","neg_dollar:$214.90;150% of Medicaid interim rate","111.20","80","","","Percent of Total Billed Charges","neg_dollar:$111.20;Percent of Total Billed Charges","","","","139.00","Fee Schedule","","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","72.28","52","","","Percent of Total Billed Charges","neg_dollar:$72.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","72.00","139.00",""
"TC99M MAG3 TO 15 MCI","A9562","HCPCS","27002311","CDM","343","RC","","Facility","Outpatient","","","611","488.80","611.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","317.72","52","","","Percent of Total Billed Charges","neg_dollar:$317.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","611.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","317.72","52","","","Percent of Total Billed Charges","neg_dollar:$317.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","317.72","52","","","Percent of Total Billed Charges","neg_dollar:$317.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","317.72","52","","","Percent of Total Billed Charges","neg_dollar:$317.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","525.46","86","","","Percent of Total Billed Charges","neg_dollar:$525.46","427.70","70","","","Percent of Total Billed Charges","neg_dollar:$427.70","317.72","52","","","Percent of Total Billed Charges","neg_dollar:$317.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","358.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$358.96;102% of Medicaid interim rate","458.25","75","","","Percent of Total Billed Charges","neg_dollar:$458.25","525.46","86","","","Percent of Total Billed Charges","neg_dollar:$525.46","427.70","70","","","Percent of Total Billed Charges","neg_dollar:$427.70","348.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$348.27;103.5% of Medicaid interim rate","611.00","150","","","Percent of Total Billed Charges","neg_dollar:$944.63;150% of Medicaid interim rate","488.80","80","","","Percent of Total Billed Charges","neg_dollar:$488.80;Percent of Total Billed Charges","","","","510.00","Fee Schedule","","317.72","52","","","Percent of Total Billed Charges","neg_dollar:$317.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","317.72","52","","","Percent of Total Billed Charges","neg_dollar:$317.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","317.00","611.00",""
"TECHNETIUM TC99M AEROSOL =< 75 MCI","A9567","HCPCS","27003129","CDM","343","RC","","Facility","Outpatient","","","424","339.20","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","249.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.09;102% of Medicaid interim rate","318.00","75","","","Percent of Total Billed Charges","neg_dollar:$318","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","241.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$241.67;103.5% of Medicaid interim rate","424.00","150","","","Percent of Total Billed Charges","neg_dollar:$655.52;150% of Medicaid interim rate","339.20","80","","","Percent of Total Billed Charges","neg_dollar:$339.20;Percent of Total Billed Charges","","","","424.00","Fee Schedule","","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.00","424.00",""
"TECHNETIUM TC99M AUTO WBC DX PER STUDY DOSE","A9569","HCPCS","27002313","CDM","343","RC","","Facility","Outpatient","","","2","1.60","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","","","","2.00","Fee Schedule","","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"GADOTERATE MEGLUMINE 7.5 MMOL/15ML IV SOSY","A9575","HCPCS","67684-2000-6","NDC","636","RC","","Facility","Outpatient","15","ML","264.56","264.56","","","","264.56","Fee Schedule","","","","","264.56","Fee Schedule","101% of Medicare Fee Schedule","","","","264.56","Fee Schedule","","137.57","52","","","Percent of Total Billed Charges","neg_dollar:$137.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","264.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","264.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","227.52","86","","","Percent of Total Billed Charges","neg_dollar:$227.52","185.19","70","","","Percent of Total Billed Charges","neg_dollar:$185.19","137.57","52","","","Percent of Total Billed Charges","neg_dollar:$137.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","155.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$155.43;102% of Medicaid interim rate","198.42","75","","","Percent of Total Billed Charges","neg_dollar:$198.42","227.52","86","","","Percent of Total Billed Charges","neg_dollar:$227.52","185.19","70","","","Percent of Total Billed Charges","neg_dollar:$185.19","150.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$150.80;103.5% of Medicaid interim rate","264.56","150","","","Percent of Total Billed Charges","neg_dollar:$409.03;150% of Medicaid interim rate","211.65","80","","","Percent of Total Billed Charges","neg_dollar:$211.65;Percent of Total Billed Charges","243.40","92","","","Percent of Total Billed Charges","neg_dollar:$243.40","137.57","52","","","Percent of Total Billed Charges","neg_dollar:$137.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","137.57","52","","","Percent of Total Billed Charges","neg_dollar:$137.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","137.00","264.00",""
"MULTIHANCE INJ PER ML","A9577","HCPCS","27002316","CDM","255","RC","","Facility","Outpatient","","","2","1.60","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"CONTRAST GADOLINIUM NOS PER ML","A9579","HCPCS","27002317","CDM","255","RC","","Facility","Outpatient","","","2","1.60","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"MESH (IMPLANTABLE) LVL 1","C1781","HCPCS","27000668","CDM","278","RC","","Facility","Outpatient","","","285","228.00","285.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","285.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","245.10","86","","","Percent of Total Billed Charges","neg_dollar:$245.10","199.50","70","","","Percent of Total Billed Charges","neg_dollar:$199.50","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","167.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$167.43;102% of Medicaid interim rate","213.75","75","","","Percent of Total Billed Charges","neg_dollar:$213.75","245.10","86","","","Percent of Total Billed Charges","neg_dollar:$245.10","199.50","70","","","Percent of Total Billed Charges","neg_dollar:$199.50","162.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$162.45;103.5% of Medicaid interim rate","285.00","150","","","Percent of Total Billed Charges","neg_dollar:$440.62;150% of Medicaid interim rate","228.00","80","","","Percent of Total Billed Charges","neg_dollar:$228;Percent of Total Billed Charges","262.20","92","","","Percent of Total Billed Charges","neg_dollar:$262.20","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","148.20","52","","","Percent of Total Billed Charges","neg_dollar:$148.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","148.00","285.00",""
"MESH (IMPLANTABLE) LVL 3","C1781","HCPCS","27000670","CDM","278","RC","","Facility","Outpatient","","","939","751.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","807.54","86","","","Percent of Total Billed Charges","neg_dollar:$807.54","657.30","70","","","Percent of Total Billed Charges","neg_dollar:$657.30","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","551.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$551.66;102% of Medicaid interim rate","704.25","75","","","Percent of Total Billed Charges","neg_dollar:$704.25","807.54","86","","","Percent of Total Billed Charges","neg_dollar:$807.54","657.30","70","","","Percent of Total Billed Charges","neg_dollar:$657.30","535.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$535.22;103.5% of Medicaid interim rate","939.00","150","","","Percent of Total Billed Charges","neg_dollar:$1451.74;150% of Medicaid interim rate","751.20","80","","","Percent of Total Billed Charges","neg_dollar:$751.20;Percent of Total Billed Charges","863.88","92","","","Percent of Total Billed Charges","neg_dollar:$863.88","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","488.28","52","","","Percent of Total Billed Charges","neg_dollar:$488.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","488.00","939.00",""
"MESH (IMPLANTABLE) LVL 4","C1781","HCPCS","27000671","CDM","278","RC","","Facility","Outpatient","","","1285","1028.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","1105.10","86","","","Percent of Total Billed Charges","neg_dollar:$1105.10","899.49","70","","","Percent of Total Billed Charges","neg_dollar:$899.49","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","754.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$754.93;102% of Medicaid interim rate","963.75","75","","","Percent of Total Billed Charges","neg_dollar:$963.75","1105.10","86","","","Percent of Total Billed Charges","neg_dollar:$1105.10","899.49","70","","","Percent of Total Billed Charges","neg_dollar:$899.49","732.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$732.44;103.5% of Medicaid interim rate","1285.00","150","","","Percent of Total Billed Charges","neg_dollar:$1986.67;150% of Medicaid interim rate","1028.00","80","","","Percent of Total Billed Charges","neg_dollar:$1028;Percent of Total Billed Charges","1182.20","92","","","Percent of Total Billed Charges","neg_dollar:$1182.20","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","668.00","1285.00",""
"MESH (IMPLANTABLE) LVL 6","C1781","HCPCS","27000673","CDM","278","RC","","Facility","Outpatient","","","3061","2448.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1591.72","52","","","Percent of Total Billed Charges","neg_dollar:$1591.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1591.72","52","","","Percent of Total Billed Charges","neg_dollar:$1591.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1591.72","52","","","Percent of Total Billed Charges","neg_dollar:$1591.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1591.72","52","","","Percent of Total Billed Charges","neg_dollar:$1591.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","2632.46","86","","","Percent of Total Billed Charges","neg_dollar:$2632.46","2142.70","70","","","Percent of Total Billed Charges","neg_dollar:$2142.70","1591.72","52","","","Percent of Total Billed Charges","neg_dollar:$1591.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","1798.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$1798.33;102% of Medicaid interim rate","2295.75","75","","","Percent of Total Billed Charges","neg_dollar:$2295.75","2632.46","86","","","Percent of Total Billed Charges","neg_dollar:$2632.46","2142.70","70","","","Percent of Total Billed Charges","neg_dollar:$2142.70","1744.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$1744.76;103.5% of Medicaid interim rate","3061.00","150","","","Percent of Total Billed Charges","neg_dollar:$4732.45;150% of Medicaid interim rate","2448.80","80","","","Percent of Total Billed Charges","neg_dollar:$2448.80;Percent of Total Billed Charges","2816.12","92","","","Percent of Total Billed Charges","neg_dollar:$2816.12","1591.72","52","","","Percent of Total Billed Charges","neg_dollar:$1591.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1591.72","52","","","Percent of Total Billed Charges","neg_dollar:$1591.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3061.00",""
"OCULAR IMP AQUEOUS DRAIN LVL 11","C1783","HCPCS","27000714","CDM","278","RC","","Facility","Outpatient","","","5710","4568.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2969.20","52","","","Percent of Total Billed Charges","neg_dollar:$2969.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2969.20","52","","","Percent of Total Billed Charges","neg_dollar:$2969.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","2969.20","52","","","Percent of Total Billed Charges","neg_dollar:$2969.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","2969.20","52","","","Percent of Total Billed Charges","neg_dollar:$2969.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","4910.60","86","","","Percent of Total Billed Charges","neg_dollar:$4910.60","3996.99","70","","","Percent of Total Billed Charges","neg_dollar:$3996.99","2969.20","52","","","Percent of Total Billed Charges","neg_dollar:$2969.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","3354.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$3354.61;102% of Medicaid interim rate","4282.50","75","","","Percent of Total Billed Charges","neg_dollar:$4282.50","4910.60","86","","","Percent of Total Billed Charges","neg_dollar:$4910.60","3996.99","70","","","Percent of Total Billed Charges","neg_dollar:$3996.99","3254.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$3254.70;103.5% of Medicaid interim rate","5710.00","150","","","Percent of Total Billed Charges","neg_dollar:$8827.94;150% of Medicaid interim rate","4568.00","80","","","Percent of Total Billed Charges","neg_dollar:$4568;Percent of Total Billed Charges","5253.20","92","","","Percent of Total Billed Charges","neg_dollar:$5253.20","2969.20","52","","","Percent of Total Billed Charges","neg_dollar:$2969.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","2969.20","52","","","Percent of Total Billed Charges","neg_dollar:$2969.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5710.00",""
"TTE 2D W OR W/O CONTR FOLLOW W CONTR F-UP","C8924","HCPCS","90000357","CDM","480","RC","","Facility","Outpatient","","","1352","1081.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1162.72","86","","","Percent of Total Billed Charges","neg_dollar:$1162.72","946.40","70","","","Percent of Total Billed Charges","neg_dollar:$946.40","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","794.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$794.29;102% of Medicaid interim rate","1014.00","75","","","Percent of Total Billed Charges","neg_dollar:$1014","1162.72","86","","","Percent of Total Billed Charges","neg_dollar:$1162.72","946.40","70","","","Percent of Total Billed Charges","neg_dollar:$946.40","770.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$770.64;103.5% of Medicaid interim rate","1352.00","150","","","Percent of Total Billed Charges","neg_dollar:$2090.25;150% of Medicaid interim rate","1081.60","80","","","Percent of Total Billed Charges","neg_dollar:$1081.60;Percent of Total Billed Charges","1243.84","92","","","Percent of Total Billed Charges","neg_dollar:$1243.84","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","703.04","52","","","Percent of Total Billed Charges","neg_dollar:$703.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","703.00","1352.00",""
"TTE W OR W/O CONTR FOLLOW W CONTR DOPPLER","C8929","HCPCS","90000358","CDM","483","RC","","Facility","Outpatient","","","4845","3876.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2519.40","52","","","Percent of Total Billed Charges","neg_dollar:$2519.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2519.40","52","","","Percent of Total Billed Charges","neg_dollar:$2519.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2519.40","52","","","Percent of Total Billed Charges","neg_dollar:$2519.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2519.40","52","","","Percent of Total Billed Charges","neg_dollar:$2519.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","4166.70","86","","","Percent of Total Billed Charges","neg_dollar:$4166.70","3391.50","70","","","Percent of Total Billed Charges","neg_dollar:$3391.50","2519.40","52","","","Percent of Total Billed Charges","neg_dollar:$2519.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","2846.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$2846.43;102% of Medicaid interim rate","3633.75","75","","","Percent of Total Billed Charges","neg_dollar:$3633.75","4166.70","86","","","Percent of Total Billed Charges","neg_dollar:$4166.70","3391.50","70","","","Percent of Total Billed Charges","neg_dollar:$3391.50","2761.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$2761.64;103.5% of Medicaid interim rate","4845.00","150","","","Percent of Total Billed Charges","neg_dollar:$7490.61;150% of Medicaid interim rate","3876.00","80","","","Percent of Total Billed Charges","neg_dollar:$3876;Percent of Total Billed Charges","4457.40","92","","","Percent of Total Billed Charges","neg_dollar:$4457.40","2519.40","52","","","Percent of Total Billed Charges","neg_dollar:$2519.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","2519.40","52","","","Percent of Total Billed Charges","neg_dollar:$2519.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4845.00",""
"BUPIVACAINE LIPOSOME 1.3 % IJ SUSP","C9290","HCPCS","65250-133-04","NDC","250","RC","","Facility","Outpatient","1","UN","3.75","3.75","","","","3.75","Fee Schedule","","","","","3.75","Fee Schedule","","","","","3.75","Fee Schedule","","","52","","3.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.95","52","","","Percent of Total Billed Charges","neg_dollar:$1.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.95","52","","","Percent of Total Billed Charges","neg_dollar:$1.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.22","86","","","Percent of Total Billed Charges","neg_dollar:$3.22","2.62","70","","","Percent of Total Billed Charges","neg_dollar:$2.62","","52","","3.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.20;102% of Medicaid interim rate","2.81","75","","","Percent of Total Billed Charges","neg_dollar:$2.81","3.22","86","","","Percent of Total Billed Charges","neg_dollar:$3.22","2.62","70","","","Percent of Total Billed Charges","neg_dollar:$2.62","2.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.13;103.5% of Medicaid interim rate","3.75","150","","","Percent of Total Billed Charges","neg_dollar:$5.80;150% of Medicaid interim rate","3.00","80","","","Percent of Total Billed Charges","neg_dollar:$3;Percent of Total Billed Charges","3.45","92","","","Percent of Total Billed Charges","neg_dollar:$3.45","1.95","52","","","Percent of Total Billed Charges","neg_dollar:$1.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.75","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"BUPIVACAINE LIPOSOME 1.3 % IJ SUSP","C9290","HCPCS","65250-133-04","NDC","636","RC","","Facility","Outpatient","1","UN","3.82","3.82","","","","3.82","Fee Schedule","","","","","3.82","Fee Schedule","101% of Medicare Fee Schedule","","","","3.82","Fee Schedule","","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.28","86","","","Percent of Total Billed Charges","neg_dollar:$3.28","2.67","70","","","Percent of Total Billed Charges","neg_dollar:$2.67","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.24;102% of Medicaid interim rate","2.86","75","","","Percent of Total Billed Charges","neg_dollar:$2.86","3.28","86","","","Percent of Total Billed Charges","neg_dollar:$3.28","2.67","70","","","Percent of Total Billed Charges","neg_dollar:$2.67","2.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.17;103.5% of Medicaid interim rate","3.82","150","","","Percent of Total Billed Charges","neg_dollar:$5.90;150% of Medicaid interim rate","3.05","80","","","Percent of Total Billed Charges","neg_dollar:$3.05;Percent of Total Billed Charges","3.51","92","","","Percent of Total Billed Charges","neg_dollar:$3.51","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"BUPIVACAINE LIPOSOME 1.3 % IJ SUSP","C9290","HCPCS","65250-133-04","NDC","636","RC","","Facility","Outpatient","1","UN","1.73","1.73","","","","1.73","Fee Schedule","","","","","1.73","Fee Schedule","101% of Medicare Fee Schedule","","","","1.73","Fee Schedule","","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.73","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.73","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.49","86","","","Percent of Total Billed Charges","neg_dollar:$1.49","1.21","70","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.01;102% of Medicaid interim rate","1.30","75","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.49","86","","","Percent of Total Billed Charges","neg_dollar:$1.49","1.21","70","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.98;103.5% of Medicaid interim rate","1.73","150","","","Percent of Total Billed Charges","neg_dollar:$2.68;150% of Medicaid interim rate","1.38","80","","","Percent of Total Billed Charges","neg_dollar:$1.38;Percent of Total Billed Charges","1.59","92","","","Percent of Total Billed Charges","neg_dollar:$1.59","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BUPIVACAINE LIPOSOME 1.3 % IJ SUSP","C9290","HCPCS","65250-133-04","NDC","636","RC","","Facility","Outpatient","1","UN","3.81","3.81","","","","3.81","Fee Schedule","","","","","3.81","Fee Schedule","101% of Medicare Fee Schedule","","","","3.81","Fee Schedule","","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.27","86","","","Percent of Total Billed Charges","neg_dollar:$3.27","2.66","70","","","Percent of Total Billed Charges","neg_dollar:$2.66","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.24;102% of Medicaid interim rate","2.86","75","","","Percent of Total Billed Charges","neg_dollar:$2.86","3.27","86","","","Percent of Total Billed Charges","neg_dollar:$3.27","2.66","70","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.17;103.5% of Medicaid interim rate","3.81","150","","","Percent of Total Billed Charges","neg_dollar:$5.89;150% of Medicaid interim rate","3.05","80","","","Percent of Total Billed Charges","neg_dollar:$3.05;Percent of Total Billed Charges","3.50","92","","","Percent of Total Billed Charges","neg_dollar:$3.50","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.98","52","","","Percent of Total Billed Charges","neg_dollar:$1.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"DIABETES OP SELF-MGMT, INDIV 30 MIN","G0108","HCPCS","90000258","CDM","942","RC","","Facility","Outpatient","","","131","104.80","131.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","131.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","112.66","86","","","Percent of Total Billed Charges","neg_dollar:$112.66","91.69","70","","","Percent of Total Billed Charges","neg_dollar:$91.69","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","76.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$76.96;102% of Medicaid interim rate","98.25","75","","","Percent of Total Billed Charges","neg_dollar:$98.25","112.66","86","","","Percent of Total Billed Charges","neg_dollar:$112.66","91.69","70","","","Percent of Total Billed Charges","neg_dollar:$91.69","74.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$74.66;103.5% of Medicaid interim rate","131.00","150","","","Percent of Total Billed Charges","neg_dollar:$202.53;150% of Medicaid interim rate","104.80","80","","","Percent of Total Billed Charges","neg_dollar:$104.80;Percent of Total Billed Charges","120.52","92","","","Percent of Total Billed Charges","neg_dollar:$120.52","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","68.12","52","","","Percent of Total Billed Charges","neg_dollar:$68.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","68.00","131.00",""
"DIABETES OP SELF-MGMT, GROUP 30 MIN","G0109","HCPCS","90000259","CDM","942","RC","","Facility","Outpatient","","","93","74.40","93.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","48.36","52","","","Percent of Total Billed Charges","neg_dollar:$48.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","93.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","48.36","52","","","Percent of Total Billed Charges","neg_dollar:$48.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","48.36","52","","","Percent of Total Billed Charges","neg_dollar:$48.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","48.36","52","","","Percent of Total Billed Charges","neg_dollar:$48.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","79.98","86","","","Percent of Total Billed Charges","neg_dollar:$79.98","65.10","70","","","Percent of Total Billed Charges","neg_dollar:$65.10","48.36","52","","","Percent of Total Billed Charges","neg_dollar:$48.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","54.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.63;102% of Medicaid interim rate","69.75","75","","","Percent of Total Billed Charges","neg_dollar:$69.75","79.98","86","","","Percent of Total Billed Charges","neg_dollar:$79.98","65.10","70","","","Percent of Total Billed Charges","neg_dollar:$65.10","53.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.01;103.5% of Medicaid interim rate","93.00","150","","","Percent of Total Billed Charges","neg_dollar:$143.78;150% of Medicaid interim rate","74.40","80","","","Percent of Total Billed Charges","neg_dollar:$74.40;Percent of Total Billed Charges","85.56","92","","","Percent of Total Billed Charges","neg_dollar:$85.56","48.36","52","","","Percent of Total Billed Charges","neg_dollar:$48.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.36","52","","","Percent of Total Billed Charges","neg_dollar:$48.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.00","93.00",""
"PULM MS THERAPY 15 MIN","G0237","HCPCS","97000010","CDM","410","RC","","Facility","Outpatient","","","135","108.00","135.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","135.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","116.10","86","","","Percent of Total Billed Charges","neg_dollar:$116.10","94.50","70","","","Percent of Total Billed Charges","neg_dollar:$94.50","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","79.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$79.31;102% of Medicaid interim rate","101.25","75","","","Percent of Total Billed Charges","neg_dollar:$101.25","116.10","86","","","Percent of Total Billed Charges","neg_dollar:$116.10","94.50","70","","","Percent of Total Billed Charges","neg_dollar:$94.50","76.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$76.94;103.5% of Medicaid interim rate","135.00","150","","","Percent of Total Billed Charges","neg_dollar:$208.71;150% of Medicaid interim rate","108.00","80","","","Percent of Total Billed Charges","neg_dollar:$108;Percent of Total Billed Charges","124.20","92","","","Percent of Total Billed Charges","neg_dollar:$124.20","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","70.00","135.00",""
"PULM FCN THERAPY 15 MIN","G0238","HCPCS","97000011","CDM","410","RC","","Facility","Outpatient","","","135","108.00","135.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","135.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","116.10","86","","","Percent of Total Billed Charges","neg_dollar:$116.10","94.50","70","","","Percent of Total Billed Charges","neg_dollar:$94.50","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","79.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$79.31;102% of Medicaid interim rate","101.25","75","","","Percent of Total Billed Charges","neg_dollar:$101.25","116.10","86","","","Percent of Total Billed Charges","neg_dollar:$116.10","94.50","70","","","Percent of Total Billed Charges","neg_dollar:$94.50","76.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$76.94;103.5% of Medicaid interim rate","135.00","150","","","Percent of Total Billed Charges","neg_dollar:$208.71;150% of Medicaid interim rate","108.00","80","","","Percent of Total Billed Charges","neg_dollar:$108;Percent of Total Billed Charges","124.20","92","","","Percent of Total Billed Charges","neg_dollar:$124.20","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","70.00","135.00",""
"PULM FCN STRENGTH 2/> INDIV","G0239","HCPCS","97000012","CDM","410","RC","","Facility","Outpatient","","","135","108.00","135.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","135.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","116.10","86","","","Percent of Total Billed Charges","neg_dollar:$116.10","94.50","70","","","Percent of Total Billed Charges","neg_dollar:$94.50","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","79.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$79.31;102% of Medicaid interim rate","101.25","75","","","Percent of Total Billed Charges","neg_dollar:$101.25","116.10","86","","","Percent of Total Billed Charges","neg_dollar:$116.10","94.50","70","","","Percent of Total Billed Charges","neg_dollar:$94.50","76.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$76.94;103.5% of Medicaid interim rate","135.00","150","","","Percent of Total Billed Charges","neg_dollar:$208.71;150% of Medicaid interim rate","108.00","80","","","Percent of Total Billed Charges","neg_dollar:$108;Percent of Total Billed Charges","124.20","92","","","Percent of Total Billed Charges","neg_dollar:$124.20","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","70.20","52","","","Percent of Total Billed Charges","neg_dollar:$70.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","70.00","135.00",""
"DIRECT REFER HOSPITAL OBSERV","G0379","HCPCS","90000266","CDM","762","RC","","Facility","Outpatient","","","166","132.80","166.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","86.32","52","","","Percent of Total Billed Charges","neg_dollar:$86.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","166.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","86.32","52","","","Percent of Total Billed Charges","neg_dollar:$86.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","86.32","52","","","Percent of Total Billed Charges","neg_dollar:$86.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","86.32","52","","","Percent of Total Billed Charges","neg_dollar:$86.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","142.76","86","","","Percent of Total Billed Charges","neg_dollar:$142.76","116.19","70","","","Percent of Total Billed Charges","neg_dollar:$116.19","86.32","52","","","Percent of Total Billed Charges","neg_dollar:$86.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","97.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$97.52;102% of Medicaid interim rate","124.50","75","","","Percent of Total Billed Charges","neg_dollar:$124.50","142.76","86","","","Percent of Total Billed Charges","neg_dollar:$142.76","116.19","70","","","Percent of Total Billed Charges","neg_dollar:$116.19","94.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$94.61;103.5% of Medicaid interim rate","166.00","150","","","Percent of Total Billed Charges","neg_dollar:$256.64;150% of Medicaid interim rate","132.80","80","","","Percent of Total Billed Charges","neg_dollar:$132.80;Percent of Total Billed Charges","152.72","92","","","Percent of Total Billed Charges","neg_dollar:$152.72","86.32","52","","","Percent of Total Billed Charges","neg_dollar:$86.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","86.32","52","","","Percent of Total Billed Charges","neg_dollar:$86.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","86.00","166.00",""
"FULL TRAUMA RESPONS W CC FAC LEV 4","G0390","HCPCS","90000188","CDM","684","RC","","Facility","Outpatient","","","1688","1350.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","877.76","52","","","Percent of Total Billed Charges","neg_dollar:$877.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","877.76","52","","","Percent of Total Billed Charges","neg_dollar:$877.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","877.76","52","","","Percent of Total Billed Charges","neg_dollar:$877.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","877.76","52","","","Percent of Total Billed Charges","neg_dollar:$877.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1451.68","86","","","Percent of Total Billed Charges","neg_dollar:$1451.68","1181.60","70","","","Percent of Total Billed Charges","neg_dollar:$1181.60","877.76","52","","","Percent of Total Billed Charges","neg_dollar:$877.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","991.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$991.69;102% of Medicaid interim rate","1266.00","75","","","Percent of Total Billed Charges","neg_dollar:$1266","1451.68","86","","","Percent of Total Billed Charges","neg_dollar:$1451.68","1181.60","70","","","Percent of Total Billed Charges","neg_dollar:$1181.60","962.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$962.16;103.5% of Medicaid interim rate","1688.00","150","","","Percent of Total Billed Charges","neg_dollar:$2609.73;150% of Medicaid interim rate","1350.40","80","","","Percent of Total Billed Charges","neg_dollar:$1350.40;Percent of Total Billed Charges","1552.96","92","","","Percent of Total Billed Charges","neg_dollar:$1552.96","877.76","52","","","Percent of Total Billed Charges","neg_dollar:$877.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","877.76","52","","","Percent of Total Billed Charges","neg_dollar:$877.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1688.00",""
"HOME SLEEP TEST/TYPE 3 PORTA","G0399","HCPCS","90000183","CDM","920","RC","","Facility","Outpatient","","","733","586.40","733.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","733.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","630.38","86","","","Percent of Total Billed Charges","neg_dollar:$630.38","513.10","70","","","Percent of Total Billed Charges","neg_dollar:$513.10","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","430.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$430.63;102% of Medicaid interim rate","549.75","75","","","Percent of Total Billed Charges","neg_dollar:$549.75","630.38","86","","","Percent of Total Billed Charges","neg_dollar:$630.38","513.10","70","","","Percent of Total Billed Charges","neg_dollar:$513.10","417.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$417.80;103.5% of Medicaid interim rate","733.00","150","","","Percent of Total Billed Charges","neg_dollar:$1133.25;150% of Medicaid interim rate","586.40","80","","","Percent of Total Billed Charges","neg_dollar:$586.40;Percent of Total Billed Charges","674.36","92","","","Percent of Total Billed Charges","neg_dollar:$674.36","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","381.16","52","","","Percent of Total Billed Charges","neg_dollar:$381.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","381.00","733.00",""
"INIT PREVNT EXAM SCREEN EKG TRACING ONLY","G0404","HCPCS","90000656","CDM","730","RC","","Facility","Outpatient","","","270","216.00","270.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","270.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","232.20","86","","","Percent of Total Billed Charges","neg_dollar:$232.20","189.00","70","","","Percent of Total Billed Charges","neg_dollar:$189","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","158.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$158.62;102% of Medicaid interim rate","202.50","75","","","Percent of Total Billed Charges","neg_dollar:$202.50","232.20","86","","","Percent of Total Billed Charges","neg_dollar:$232.20","189.00","70","","","Percent of Total Billed Charges","neg_dollar:$189","153.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$153.89;103.5% of Medicaid interim rate","270.00","150","","","Percent of Total Billed Charges","neg_dollar:$417.43;150% of Medicaid interim rate","216.00","80","","","Percent of Total Billed Charges","neg_dollar:$216;Percent of Total Billed Charges","248.40","92","","","Percent of Total Billed Charges","neg_dollar:$248.40","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","140.40","52","","","Percent of Total Billed Charges","neg_dollar:$140.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","140.00","270.00",""
"ABATACEPT 250 MG IV SOLR","J0129","HCPCS","00003-2187-13","NDC","636","RC","","Facility","Outpatient","250","ME","118.84","118.84","","","","118.84","Fee Schedule","","","","","118.84","Fee Schedule","101% of Medicare Fee Schedule","","","","118.84","Fee Schedule","","61.80","52","","","Percent of Total Billed Charges","neg_dollar:$61.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","118.84","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","118.84","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","102.20","86","","","Percent of Total Billed Charges","neg_dollar:$102.20","83.19","70","","","Percent of Total Billed Charges","neg_dollar:$83.19","61.80","52","","","Percent of Total Billed Charges","neg_dollar:$61.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","69.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$69.82;102% of Medicaid interim rate","89.13","75","","","Percent of Total Billed Charges","neg_dollar:$89.13","102.20","86","","","Percent of Total Billed Charges","neg_dollar:$102.20","83.19","70","","","Percent of Total Billed Charges","neg_dollar:$83.19","67.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$67.74;103.5% of Medicaid interim rate","118.84","150","","","Percent of Total Billed Charges","neg_dollar:$183.74;150% of Medicaid interim rate","95.07","80","","","Percent of Total Billed Charges","neg_dollar:$95.07;Percent of Total Billed Charges","109.34","92","","","Percent of Total Billed Charges","neg_dollar:$109.34","61.80","52","","","Percent of Total Billed Charges","neg_dollar:$61.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","61.80","52","","","Percent of Total Billed Charges","neg_dollar:$61.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","61.00","118.00",""
"ACETAMINOPHEN 10 MG/ML IV SOLN","J0131","HCPCS","00781-3156-06","NDC","636","RC","","Facility","Outpatient","1","ML","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","86","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% of Medicaid interim rate","0.83","75","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.95","86","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.71;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.02","92","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ACETAMINOPHEN 10 MG/ML IV SOLN","J0131","HCPCS","00781-3156-95","NDC","636","RC","","Facility","Outpatient","1","ML","1.09","1.09","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","101% of Medicare Fee Schedule","","","","1.09","Fee Schedule","","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.09","150","","","Percent of Total Billed Charges","neg_dollar:$1.68;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.00","92","","","Percent of Total Billed Charges","neg_dollar:$1","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ACETAMINOPHEN 10 MG/ML IV SOLN","J0131","HCPCS","00781-3156-06","NDC","250","RC","","Facility","Outpatient","1","ML","1.09","1.09","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","","52","","1.09","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.09","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.09","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ACETAMINOPHEN 10 MG/ML IV SOLN","J0137","HCPCS","24201-100-01","NDC","636","RC","","Facility","Outpatient","1","ML","1.96","1.96","","","","1.96","Fee Schedule","","","","","1.96","Fee Schedule","101% of Medicare Fee Schedule","","","","1.96","Fee Schedule","","1.02","52","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","86","","","Percent of Total Billed Charges","neg_dollar:$1.69","1.37","70","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.02","52","","","Percent of Total Billed Charges","neg_dollar:$1.02;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.15;102% of Medicaid interim rate","1.47","75","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.69","86","","","Percent of Total Billed Charges","neg_dollar:$1.69","1.37","70","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.12;103.5% of Medicaid interim rate","1.96","150","","","Percent of Total Billed Charges","neg_dollar:$3.04;150% of Medicaid interim rate","1.57","80","","","Percent of Total Billed Charges","neg_dollar:$1.57;Percent of Total Billed Charges","1.81","92","","","Percent of Total Billed Charges","neg_dollar:$1.81","1.02","52","","","Percent of Total Billed Charges","neg_dollar:$1.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","52","","","Percent of Total Billed Charges","neg_dollar:$1.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ACETAMINOPHEN 10 MG/ML IV SOLN","J0137","HCPCS","24201-100-01","NDC","636","RC","","Facility","Outpatient","1","ML","1.09","1.09","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","101% of Medicare Fee Schedule","","","","1.09","Fee Schedule","","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.09","150","","","Percent of Total Billed Charges","neg_dollar:$1.68;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.00","92","","","Percent of Total Billed Charges","neg_dollar:$1","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ACETAMINOPHEN 10 MG/ML IV SOLN","J0137","HCPCS","24201-100-01","NDC","250","RC","","Facility","Outpatient","1","ML","1.09","1.09","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","","52","","1.09","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.09","150","","","Percent of Total Billed Charges","neg_dollar:$1.68;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.00","92","","","Percent of Total Billed Charges","neg_dollar:$1","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.09","Fee Schedule","","1.00","1.00",""
"ACETAMINOPHEN 10 MG/ML IV SOLN","J0137","HCPCS","24201-100-01","NDC","250","RC","","Facility","Outpatient","1","ML","0.10","0.10","","","","0.10","Fee Schedule","","","","","0.10","Fee Schedule","","","","","0.10","Fee Schedule","","","52","","0.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.09","86","","","Percent of Total Billed Charges","neg_dollar:$0.09","0.07","70","","","Percent of Total Billed Charges","neg_dollar:$0.07","","52","","0.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.06;102% of Medicaid interim rate","0.08","75","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.09","86","","","Percent of Total Billed Charges","neg_dollar:$0.09","0.07","70","","","Percent of Total Billed Charges","neg_dollar:$0.07","0.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.06;103.5% of Medicaid interim rate","0.10","150","","","Percent of Total Billed Charges","neg_dollar:$0.16;150% of Medicaid interim rate","0.08","80","","","Percent of Total Billed Charges","neg_dollar:$0.08;Percent of Total Billed Charges","0.10","92","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.10","Fee Schedule","","1.00","1.00",""
"ADENOSINE 6 MG/2ML IV SOLN","J0153","HCPCS","67457-855-00","NDC","636","RC","","Facility","Outpatient","2","ML","13.66","13.66","","","","13.66","Fee Schedule","","","","","13.66","Fee Schedule","101% of Medicare Fee Schedule","","","","6.00","Fee Schedule","","7.10","52","","","Percent of Total Billed Charges","neg_dollar:$7.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.75","86","","","Percent of Total Billed Charges","neg_dollar:$11.75","9.56","70","","","Percent of Total Billed Charges","neg_dollar:$9.56","7.10","52","","","Percent of Total Billed Charges","neg_dollar:$7.10;105% Medicare Outpatient Cost to Charge Ratio of 52%","8.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.02;102% of Medicaid interim rate","10.24","75","","","Percent of Total Billed Charges","neg_dollar:$10.24","11.75","86","","","Percent of Total Billed Charges","neg_dollar:$11.75","9.56","70","","","Percent of Total Billed Charges","neg_dollar:$9.56","7.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.78;103.5% of Medicaid interim rate","13.66","150","","","Percent of Total Billed Charges","neg_dollar:$21.12;150% of Medicaid interim rate","10.93","80","","","Percent of Total Billed Charges","neg_dollar:$10.93;Percent of Total Billed Charges","12.57","92","","","Percent of Total Billed Charges","neg_dollar:$12.57","7.10","52","","","Percent of Total Billed Charges","neg_dollar:$7.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.10","52","","","Percent of Total Billed Charges","neg_dollar:$7.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","13.00",""
"EPINEPHRINE PF 1 MG/ML IJ SOLN","J0166","HCPCS","54288-103-10","NDC","636","RC","","Facility","Outpatient","1","ML","10.95","10.95","","","","10.95","Fee Schedule","","","","","10.95","Fee Schedule","101% of Medicare Fee Schedule","","","","10.95","Fee Schedule","","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.41","86","","","Percent of Total Billed Charges","neg_dollar:$9.41","7.66","70","","","Percent of Total Billed Charges","neg_dollar:$7.66","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.43;102% of Medicaid interim rate","8.21","75","","","Percent of Total Billed Charges","neg_dollar:$8.21","9.41","86","","","Percent of Total Billed Charges","neg_dollar:$9.41","7.66","70","","","Percent of Total Billed Charges","neg_dollar:$7.66","6.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.24;103.5% of Medicaid interim rate","10.95","150","","","Percent of Total Billed Charges","neg_dollar:$16.92;150% of Medicaid interim rate","8.76","80","","","Percent of Total Billed Charges","neg_dollar:$8.76;Percent of Total Billed Charges","10.07","92","","","Percent of Total Billed Charges","neg_dollar:$10.07","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN","J0169","HCPCS","42023-159-01","NDC","636","RC","","Facility","Outpatient","1","ML","24.87","24.87","","","","24.87","Fee Schedule","","","","","24.87","Fee Schedule","101% of Medicare Fee Schedule","","","","24.87","Fee Schedule","","12.93","52","","","Percent of Total Billed Charges","neg_dollar:$12.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","21.39","86","","","Percent of Total Billed Charges","neg_dollar:$21.39","17.41","70","","","Percent of Total Billed Charges","neg_dollar:$17.41","12.93","52","","","Percent of Total Billed Charges","neg_dollar:$12.93;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.61;102% of Medicaid interim rate","18.65","75","","","Percent of Total Billed Charges","neg_dollar:$18.65","21.39","86","","","Percent of Total Billed Charges","neg_dollar:$21.39","17.41","70","","","Percent of Total Billed Charges","neg_dollar:$17.41","14.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.17;103.5% of Medicaid interim rate","24.87","150","","","Percent of Total Billed Charges","neg_dollar:$38.45;150% of Medicaid interim rate","19.90","80","","","Percent of Total Billed Charges","neg_dollar:$19.90;Percent of Total Billed Charges","22.88","92","","","Percent of Total Billed Charges","neg_dollar:$22.88","12.93","52","","","Percent of Total Billed Charges","neg_dollar:$12.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.93","52","","","Percent of Total Billed Charges","neg_dollar:$12.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","24.00",""
"EPINEPHRINE 1 MG/10ML IV SOSY","J0171","HCPCS","76329-3318-1","NDC","636","RC","","Facility","Outpatient","10","ML","11.25","11.25","","","","11.25","Fee Schedule","","","","","11.25","Fee Schedule","101% of Medicare Fee Schedule","","","","11.25","Fee Schedule","","5.85","52","","","Percent of Total Billed Charges","neg_dollar:$5.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.67","86","","","Percent of Total Billed Charges","neg_dollar:$9.67","7.87","70","","","Percent of Total Billed Charges","neg_dollar:$7.87","5.85","52","","","Percent of Total Billed Charges","neg_dollar:$5.85;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.60;102% of Medicaid interim rate","8.43","75","","","Percent of Total Billed Charges","neg_dollar:$8.43","9.67","86","","","Percent of Total Billed Charges","neg_dollar:$9.67","7.87","70","","","Percent of Total Billed Charges","neg_dollar:$7.87","6.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.41;103.5% of Medicaid interim rate","11.25","150","","","Percent of Total Billed Charges","neg_dollar:$17.39;150% of Medicaid interim rate","9.00","80","","","Percent of Total Billed Charges","neg_dollar:$9;Percent of Total Billed Charges","10.35","92","","","Percent of Total Billed Charges","neg_dollar:$10.35","5.85","52","","","Percent of Total Billed Charges","neg_dollar:$5.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.85","52","","","Percent of Total Billed Charges","neg_dollar:$5.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","11.00",""
"EPINEPHRINE PF 1 MG/ML IJ SOLN","J0171","HCPCS","54288-103-10","NDC","636","RC","","Facility","Outpatient","1","ML","23.03","23.03","","","","23.03","Fee Schedule","","","","","23.03","Fee Schedule","101% of Medicare Fee Schedule","","","","23.03","Fee Schedule","","11.97","52","","","Percent of Total Billed Charges","neg_dollar:$11.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","19.80","86","","","Percent of Total Billed Charges","neg_dollar:$19.80","16.12","70","","","Percent of Total Billed Charges","neg_dollar:$16.12","11.97","52","","","Percent of Total Billed Charges","neg_dollar:$11.97;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.53;102% of Medicaid interim rate","17.27","75","","","Percent of Total Billed Charges","neg_dollar:$17.27","19.80","86","","","Percent of Total Billed Charges","neg_dollar:$19.80","16.12","70","","","Percent of Total Billed Charges","neg_dollar:$16.12","13.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.12;103.5% of Medicaid interim rate","23.03","150","","","Percent of Total Billed Charges","neg_dollar:$35.61;150% of Medicaid interim rate","18.42","80","","","Percent of Total Billed Charges","neg_dollar:$18.42;Percent of Total Billed Charges","21.19","92","","","Percent of Total Billed Charges","neg_dollar:$21.19","11.97","52","","","Percent of Total Billed Charges","neg_dollar:$11.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.97","52","","","Percent of Total Billed Charges","neg_dollar:$11.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.00","23.00",""
"EPINEPHRINE 1 MG/10ML IJ SOSY","J0171","HCPCS","76329-3316-1","NDC","636","RC","","Facility","Outpatient","10","ML","3.72","3.72","","","","3.72","Fee Schedule","","","","","3.72","Fee Schedule","101% of Medicare Fee Schedule","","","","3.72","Fee Schedule","","1.93","52","","","Percent of Total Billed Charges","neg_dollar:$1.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.19","86","","","Percent of Total Billed Charges","neg_dollar:$3.19","2.60","70","","","Percent of Total Billed Charges","neg_dollar:$2.60","1.93","52","","","Percent of Total Billed Charges","neg_dollar:$1.93;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.18;102% of Medicaid interim rate","2.79","75","","","Percent of Total Billed Charges","neg_dollar:$2.79","3.19","86","","","Percent of Total Billed Charges","neg_dollar:$3.19","2.60","70","","","Percent of Total Billed Charges","neg_dollar:$2.60","2.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.12;103.5% of Medicaid interim rate","3.72","150","","","Percent of Total Billed Charges","neg_dollar:$5.75;150% of Medicaid interim rate","2.97","80","","","Percent of Total Billed Charges","neg_dollar:$2.97;Percent of Total Billed Charges","3.42","92","","","Percent of Total Billed Charges","neg_dollar:$3.42","1.93","52","","","Percent of Total Billed Charges","neg_dollar:$1.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.93","52","","","Percent of Total Billed Charges","neg_dollar:$1.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN","J0171","HCPCS","42023-159-01","NDC","636","RC","","Facility","Outpatient","1","ML","20.47","20.47","","","","20.47","Fee Schedule","","","","","20.47","Fee Schedule","101% of Medicare Fee Schedule","","","","20.47","Fee Schedule","","10.64","52","","","Percent of Total Billed Charges","neg_dollar:$10.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.61","86","","","Percent of Total Billed Charges","neg_dollar:$17.61","14.33","70","","","Percent of Total Billed Charges","neg_dollar:$14.33","10.64","52","","","Percent of Total Billed Charges","neg_dollar:$10.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","12.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.03;102% of Medicaid interim rate","15.35","75","","","Percent of Total Billed Charges","neg_dollar:$15.35","17.61","86","","","Percent of Total Billed Charges","neg_dollar:$17.61","14.33","70","","","Percent of Total Billed Charges","neg_dollar:$14.33","11.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.67;103.5% of Medicaid interim rate","20.47","150","","","Percent of Total Billed Charges","neg_dollar:$31.65;150% of Medicaid interim rate","16.38","80","","","Percent of Total Billed Charges","neg_dollar:$16.38;Percent of Total Billed Charges","18.83","92","","","Percent of Total Billed Charges","neg_dollar:$18.83","10.64","52","","","Percent of Total Billed Charges","neg_dollar:$10.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.64","52","","","Percent of Total Billed Charges","neg_dollar:$10.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.00","20.00",""
"EPINEPHRINE PF 1 MG/ML IJ SOLN","J0173","HCPCS","54288-103-10","NDC","636","RC","","Facility","Outpatient","1","ML","13.52","13.52","","","","13.52","Fee Schedule","","","","","13.52","Fee Schedule","101% of Medicare Fee Schedule","","","","13.52","Fee Schedule","","7.03","52","","","Percent of Total Billed Charges","neg_dollar:$7.03;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.52","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.52","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.63","86","","","Percent of Total Billed Charges","neg_dollar:$11.63","9.46","70","","","Percent of Total Billed Charges","neg_dollar:$9.46","7.03","52","","","Percent of Total Billed Charges","neg_dollar:$7.03;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.94;102% of Medicaid interim rate","10.14","75","","","Percent of Total Billed Charges","neg_dollar:$10.14","11.63","86","","","Percent of Total Billed Charges","neg_dollar:$11.63","9.46","70","","","Percent of Total Billed Charges","neg_dollar:$9.46","7.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.71;103.5% of Medicaid interim rate","13.52","150","","","Percent of Total Billed Charges","neg_dollar:$20.91;150% of Medicaid interim rate","10.82","80","","","Percent of Total Billed Charges","neg_dollar:$10.82;Percent of Total Billed Charges","12.44","92","","","Percent of Total Billed Charges","neg_dollar:$12.44","7.03","52","","","Percent of Total Billed Charges","neg_dollar:$7.03;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.03","52","","","Percent of Total Billed Charges","neg_dollar:$7.03;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","13.00",""
"REMDESIVIR INJECTION","J0248","HCPCS","61958-2901-2","NDC","636","RC","","Facility","Outpatient","1","UN","12.88","12.88","","","","12.88","Fee Schedule","","","","","12.88","Fee Schedule","101% of Medicare Fee Schedule","","","","12.88","Fee Schedule","","6.69","52","","","Percent of Total Billed Charges","neg_dollar:$6.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.07","86","","","Percent of Total Billed Charges","neg_dollar:$11.07","9.01","70","","","Percent of Total Billed Charges","neg_dollar:$9.01","6.69","52","","","Percent of Total Billed Charges","neg_dollar:$6.69;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.56;102% of Medicaid interim rate","9.66","75","","","Percent of Total Billed Charges","neg_dollar:$9.66","11.07","86","","","Percent of Total Billed Charges","neg_dollar:$11.07","9.01","70","","","Percent of Total Billed Charges","neg_dollar:$9.01","7.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.34;103.5% of Medicaid interim rate","12.88","150","","","Percent of Total Billed Charges","neg_dollar:$19.91;150% of Medicaid interim rate","10.30","80","","","Percent of Total Billed Charges","neg_dollar:$10.30;Percent of Total Billed Charges","11.85","92","","","Percent of Total Billed Charges","neg_dollar:$11.85","6.69","52","","","Percent of Total Billed Charges","neg_dollar:$6.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.69","52","","","Percent of Total Billed Charges","neg_dollar:$6.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","12.00",""
"REMDESIVIR INJECTION","J0248","HCPCS","61958-2901-2","NDC","250","RC","","Facility","Outpatient","1","UN","12.73","12.73","","","","12.73","Fee Schedule","","","","","12.73","Fee Schedule","","","","","12.73","Fee Schedule","","","52","","12.73","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.62","52","","","Percent of Total Billed Charges","neg_dollar:$6.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.62","52","","","Percent of Total Billed Charges","neg_dollar:$6.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.95","86","","","Percent of Total Billed Charges","neg_dollar:$10.95","8.91","70","","","Percent of Total Billed Charges","neg_dollar:$8.91","","52","","12.73","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.48;102% of Medicaid interim rate","9.55","75","","","Percent of Total Billed Charges","neg_dollar:$9.55","10.95","86","","","Percent of Total Billed Charges","neg_dollar:$10.95","8.91","70","","","Percent of Total Billed Charges","neg_dollar:$8.91","7.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.26;103.5% of Medicaid interim rate","12.73","150","","","Percent of Total Billed Charges","neg_dollar:$19.69;150% of Medicaid interim rate","10.19","80","","","Percent of Total Billed Charges","neg_dollar:$10.19;Percent of Total Billed Charges","11.72","92","","","Percent of Total Billed Charges","neg_dollar:$11.72","6.62","52","","","Percent of Total Billed Charges","neg_dollar:$6.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.73","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","12.00",""
"AMIODARONE HCL IN DEXTROSE 150-4.21 MG/100ML-% IV SOLN","J0283","HCPCS","43066-150-10","NDC","636","RC","","Facility","Outpatient","1","UN","31.38","31.38","","","","31.38","Fee Schedule","","","","","31.38","Fee Schedule","101% of Medicare Fee Schedule","","","","31.38","Fee Schedule","","16.31","52","","","Percent of Total Billed Charges","neg_dollar:$16.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","26.98","86","","","Percent of Total Billed Charges","neg_dollar:$26.98","21.96","70","","","Percent of Total Billed Charges","neg_dollar:$21.96","16.31","52","","","Percent of Total Billed Charges","neg_dollar:$16.31;105% Medicare Outpatient Cost to Charge Ratio of 52%","18.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.43;102% of Medicaid interim rate","23.53","75","","","Percent of Total Billed Charges","neg_dollar:$23.53","26.98","86","","","Percent of Total Billed Charges","neg_dollar:$26.98","21.96","70","","","Percent of Total Billed Charges","neg_dollar:$21.96","17.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.88;103.5% of Medicaid interim rate","31.38","150","","","Percent of Total Billed Charges","neg_dollar:$48.51;150% of Medicaid interim rate","25.10","80","","","Percent of Total Billed Charges","neg_dollar:$25.10;Percent of Total Billed Charges","28.86","92","","","Percent of Total Billed Charges","neg_dollar:$28.86","16.31","52","","","Percent of Total Billed Charges","neg_dollar:$16.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.31","52","","","Percent of Total Billed Charges","neg_dollar:$16.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","31.00",""
"AMIODARONE HCL IN DEXTROSE 150-4.21 MG/100ML-% IV SOLN","J0283","HCPCS","43066-150-10","NDC","250","RC","","Facility","Outpatient","1","UN","31.38","31.38","","","","31.38","Fee Schedule","","","","","31.38","Fee Schedule","","","","","31.38","Fee Schedule","","","52","","31.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.31","52","","","Percent of Total Billed Charges","neg_dollar:$16.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.31","52","","","Percent of Total Billed Charges","neg_dollar:$16.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.98","86","","","Percent of Total Billed Charges","neg_dollar:$26.98","21.96","70","","","Percent of Total Billed Charges","neg_dollar:$21.96","","52","","31.38","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","18.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.43;102% of Medicaid interim rate","23.53","75","","","Percent of Total Billed Charges","neg_dollar:$23.53","26.98","86","","","Percent of Total Billed Charges","neg_dollar:$26.98","21.96","70","","","Percent of Total Billed Charges","neg_dollar:$21.96","17.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.88;103.5% of Medicaid interim rate","31.38","150","","","Percent of Total Billed Charges","neg_dollar:$48.51;150% of Medicaid interim rate","25.10","80","","","Percent of Total Billed Charges","neg_dollar:$25.10;Percent of Total Billed Charges","28.86","92","","","Percent of Total Billed Charges","neg_dollar:$28.86","16.31","52","","","Percent of Total Billed Charges","neg_dollar:$16.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","31.38","Fee Schedule","","16.00","31.00",""
"AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN","J0283","HCPCS","43066-360-20","NDC","250","RC","","Facility","Outpatient","1","UN","14.99","14.99","","","","14.99","Fee Schedule","","","","","14.99","Fee Schedule","","","","","14.99","Fee Schedule","","","52","","14.99","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.79","52","","","Percent of Total Billed Charges","neg_dollar:$7.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.79","52","","","Percent of Total Billed Charges","neg_dollar:$7.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.89","86","","","Percent of Total Billed Charges","neg_dollar:$12.89","10.49","70","","","Percent of Total Billed Charges","neg_dollar:$10.49","","52","","14.99","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.80;102% of Medicaid interim rate","11.24","75","","","Percent of Total Billed Charges","neg_dollar:$11.24","12.89","86","","","Percent of Total Billed Charges","neg_dollar:$12.89","10.49","70","","","Percent of Total Billed Charges","neg_dollar:$10.49","8.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.54;103.5% of Medicaid interim rate","14.99","150","","","Percent of Total Billed Charges","neg_dollar:$23.17;150% of Medicaid interim rate","11.99","80","","","Percent of Total Billed Charges","neg_dollar:$11.99;Percent of Total Billed Charges","13.79","92","","","Percent of Total Billed Charges","neg_dollar:$13.79","7.79","52","","","Percent of Total Billed Charges","neg_dollar:$7.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","14.99","Fee Schedule","","7.00","14.00",""
"AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN","J0283","HCPCS","43066-360-20","NDC","636","RC","","Facility","Outpatient","1","UN","14.99","14.99","","","","14.99","Fee Schedule","","","","","14.99","Fee Schedule","101% of Medicare Fee Schedule","","","","14.99","Fee Schedule","","7.79","52","","","Percent of Total Billed Charges","neg_dollar:$7.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","14.99","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","14.99","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.89","86","","","Percent of Total Billed Charges","neg_dollar:$12.89","10.49","70","","","Percent of Total Billed Charges","neg_dollar:$10.49","7.79","52","","","Percent of Total Billed Charges","neg_dollar:$7.79;105% Medicare Outpatient Cost to Charge Ratio of 52%","8.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.80;102% of Medicaid interim rate","11.24","75","","","Percent of Total Billed Charges","neg_dollar:$11.24","12.89","86","","","Percent of Total Billed Charges","neg_dollar:$12.89","10.49","70","","","Percent of Total Billed Charges","neg_dollar:$10.49","8.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.54;103.5% of Medicaid interim rate","14.99","150","","","Percent of Total Billed Charges","neg_dollar:$23.17;150% of Medicaid interim rate","11.99","80","","","Percent of Total Billed Charges","neg_dollar:$11.99;Percent of Total Billed Charges","13.79","92","","","Percent of Total Billed Charges","neg_dollar:$13.79","7.79","52","","","Percent of Total Billed Charges","neg_dollar:$7.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.79","52","","","Percent of Total Billed Charges","neg_dollar:$7.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","14.00",""
"AMPICILLIN SODIUM 1 G IJ SOLR","J0290","HCPCS","00781-3404-85","NDC","250","RC","","Facility","Outpatient","1","GM","57.50","57.50","","","","57.50","Fee Schedule","","","","","57.50","Fee Schedule","","","","","57.50","Fee Schedule","","","52","","57.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","29.90","52","","","Percent of Total Billed Charges","neg_dollar:$29.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","29.90","52","","","Percent of Total Billed Charges","neg_dollar:$29.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","49.45","86","","","Percent of Total Billed Charges","neg_dollar:$49.45","40.25","70","","","Percent of Total Billed Charges","neg_dollar:$40.25","","52","","57.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","33.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.78;102% of Medicaid interim rate","43.13","75","","","Percent of Total Billed Charges","neg_dollar:$43.13","49.45","86","","","Percent of Total Billed Charges","neg_dollar:$49.45","40.25","70","","","Percent of Total Billed Charges","neg_dollar:$40.25","32.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.77;103.5% of Medicaid interim rate","57.50","150","","","Percent of Total Billed Charges","neg_dollar:$88.91;150% of Medicaid interim rate","46.00","80","","","Percent of Total Billed Charges","neg_dollar:$46;Percent of Total Billed Charges","52.90","92","","","Percent of Total Billed Charges","neg_dollar:$52.90","29.90","52","","","Percent of Total Billed Charges","neg_dollar:$29.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","57.50","Fee Schedule","","29.00","57.00",""
"AMPICILLIN SODIUM 2 G IJ SOLR","J0290","HCPCS","55150-114-20","NDC","250","RC","","Facility","Outpatient","2","GM","25.43","25.43","","","","25.43","Fee Schedule","","","","","25.43","Fee Schedule","","","","","25.43","Fee Schedule","","","52","","25.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.22","52","","","Percent of Total Billed Charges","neg_dollar:$13.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.22","52","","","Percent of Total Billed Charges","neg_dollar:$13.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.87","86","","","Percent of Total Billed Charges","neg_dollar:$21.87","17.80","70","","","Percent of Total Billed Charges","neg_dollar:$17.80","","52","","25.43","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.94;102% of Medicaid interim rate","19.07","75","","","Percent of Total Billed Charges","neg_dollar:$19.07","21.87","86","","","Percent of Total Billed Charges","neg_dollar:$21.87","17.80","70","","","Percent of Total Billed Charges","neg_dollar:$17.80","14.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.49;103.5% of Medicaid interim rate","25.43","150","","","Percent of Total Billed Charges","neg_dollar:$39.32;150% of Medicaid interim rate","20.35","80","","","Percent of Total Billed Charges","neg_dollar:$20.35;Percent of Total Billed Charges","23.40","92","","","Percent of Total Billed Charges","neg_dollar:$23.40","13.22","52","","","Percent of Total Billed Charges","neg_dollar:$13.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.43","Fee Schedule","","13.00","25.00",""
"AMPICILLIN SODIUM 2 G IJ SOLR","J0290","HCPCS","72485-422-10","NDC","250","RC","","Facility","Outpatient","2","GM","23.62","23.62","","","","23.62","Fee Schedule","","","","","23.62","Fee Schedule","","","","","23.62","Fee Schedule","","","52","","23.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.28","52","","","Percent of Total Billed Charges","neg_dollar:$12.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.28","52","","","Percent of Total Billed Charges","neg_dollar:$12.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.31","86","","","Percent of Total Billed Charges","neg_dollar:$20.31","16.53","70","","","Percent of Total Billed Charges","neg_dollar:$16.53","","52","","23.62","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.87;102% of Medicaid interim rate","17.71","75","","","Percent of Total Billed Charges","neg_dollar:$17.71","20.31","86","","","Percent of Total Billed Charges","neg_dollar:$20.31","16.53","70","","","Percent of Total Billed Charges","neg_dollar:$16.53","13.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.46;103.5% of Medicaid interim rate","23.62","150","","","Percent of Total Billed Charges","neg_dollar:$36.52;150% of Medicaid interim rate","18.90","80","","","Percent of Total Billed Charges","neg_dollar:$18.90;Percent of Total Billed Charges","21.73","92","","","Percent of Total Billed Charges","neg_dollar:$21.73","12.28","52","","","Percent of Total Billed Charges","neg_dollar:$12.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","23.62","Fee Schedule","","12.00","23.00",""
"AMPICILLIN SODIUM 2 G IJ SOLR","J0290","HCPCS","72485-422-01","NDC","636","RC","","Facility","Outpatient","2","GM","23.62","23.62","","","","23.62","Fee Schedule","","","","","23.62","Fee Schedule","101% of Medicare Fee Schedule","","","","23.62","Fee Schedule","","12.28","52","","","Percent of Total Billed Charges","neg_dollar:$12.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.31","86","","","Percent of Total Billed Charges","neg_dollar:$20.31","16.53","70","","","Percent of Total Billed Charges","neg_dollar:$16.53","12.28","52","","","Percent of Total Billed Charges","neg_dollar:$12.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.87;102% of Medicaid interim rate","17.71","75","","","Percent of Total Billed Charges","neg_dollar:$17.71","20.31","86","","","Percent of Total Billed Charges","neg_dollar:$20.31","16.53","70","","","Percent of Total Billed Charges","neg_dollar:$16.53","13.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.46;103.5% of Medicaid interim rate","23.62","150","","","Percent of Total Billed Charges","neg_dollar:$36.52;150% of Medicaid interim rate","18.90","80","","","Percent of Total Billed Charges","neg_dollar:$18.90;Percent of Total Billed Charges","21.73","92","","","Percent of Total Billed Charges","neg_dollar:$21.73","12.28","52","","","Percent of Total Billed Charges","neg_dollar:$12.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.28","52","","","Percent of Total Billed Charges","neg_dollar:$12.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","23.00",""
"AMPICILLIN SODIUM 2 G IJ SOLR","J0290","HCPCS","72485-422-01","NDC","250","RC","","Facility","Outpatient","2","GM","24.11","24.11","","","","24.11","Fee Schedule","","","","","24.11","Fee Schedule","","","","","24.11","Fee Schedule","","","52","","24.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.53","52","","","Percent of Total Billed Charges","neg_dollar:$12.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.53","52","","","Percent of Total Billed Charges","neg_dollar:$12.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.73","86","","","Percent of Total Billed Charges","neg_dollar:$20.73","16.87","70","","","Percent of Total Billed Charges","neg_dollar:$16.87","","52","","24.11","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.16;102% of Medicaid interim rate","18.08","75","","","Percent of Total Billed Charges","neg_dollar:$18.08","20.73","86","","","Percent of Total Billed Charges","neg_dollar:$20.73","16.87","70","","","Percent of Total Billed Charges","neg_dollar:$16.87","13.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.74;103.5% of Medicaid interim rate","24.11","150","","","Percent of Total Billed Charges","neg_dollar:$37.28;150% of Medicaid interim rate","19.29","80","","","Percent of Total Billed Charges","neg_dollar:$19.29;Percent of Total Billed Charges","22.18","92","","","Percent of Total Billed Charges","neg_dollar:$22.18","12.53","52","","","Percent of Total Billed Charges","neg_dollar:$12.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","24.11","Fee Schedule","","12.00","24.00",""
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","J0295","HCPCS","44567-211-10","NDC","250","RC","","Facility","Outpatient","3","GM","59.21","59.21","","","","43.00","Fee Schedule","","","","","59.00","Fee Schedule","","","","","46.00","Fee Schedule","","","52","","59.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","30.79","52","","","Percent of Total Billed Charges","neg_dollar:$30.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.79","52","","","Percent of Total Billed Charges","neg_dollar:$30.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.92","86","","","Percent of Total Billed Charges","neg_dollar:$50.92","41.44","70","","","Percent of Total Billed Charges","neg_dollar:$41.44","","52","","59.21","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","34.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.78;102% of Medicaid interim rate","44.41","75","","","Percent of Total Billed Charges","neg_dollar:$44.41","50.92","86","","","Percent of Total Billed Charges","neg_dollar:$50.92","41.44","70","","","Percent of Total Billed Charges","neg_dollar:$41.44","33.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.75;103.5% of Medicaid interim rate","59.21","150","","","Percent of Total Billed Charges","neg_dollar:$91.54;150% of Medicaid interim rate","47.37","80","","","Percent of Total Billed Charges","neg_dollar:$47.37;Percent of Total Billed Charges","54.47","92","","","Percent of Total Billed Charges","neg_dollar:$54.47","30.79","52","","","Percent of Total Billed Charges","neg_dollar:$30.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","59.21","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","30.00","59.00",""
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR","J0295","HCPCS","44567-211-10","NDC","636","RC","","Facility","Outpatient","3","GM","59.70","59.70","","","","43.00","Fee Schedule","","","","","59.00","Fee Schedule","101% of Medicare Fee Schedule","","","","46.00","Fee Schedule","","31.04","52","","","Percent of Total Billed Charges","neg_dollar:$31.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","59.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","59.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","51.34","86","","","Percent of Total Billed Charges","neg_dollar:$51.34","41.79","70","","","Percent of Total Billed Charges","neg_dollar:$41.79","31.04","52","","","Percent of Total Billed Charges","neg_dollar:$31.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","35.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.07;102% of Medicaid interim rate","44.77","75","","","Percent of Total Billed Charges","neg_dollar:$44.77","51.34","86","","","Percent of Total Billed Charges","neg_dollar:$51.34","41.79","70","","","Percent of Total Billed Charges","neg_dollar:$41.79","34.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.02;103.5% of Medicaid interim rate","59.70","150","","","Percent of Total Billed Charges","neg_dollar:$92.29;150% of Medicaid interim rate","47.76","80","","","Percent of Total Billed Charges","neg_dollar:$47.76;Percent of Total Billed Charges","54.92","92","","","Percent of Total Billed Charges","neg_dollar:$54.92","31.04","52","","","Percent of Total Billed Charges","neg_dollar:$31.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","31.04","52","","","Percent of Total Billed Charges","neg_dollar:$31.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","31.00","59.00",""
"SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN","J0330","HCPCS","70069-301-25","NDC","636","RC","","Facility","Outpatient","1","ML","10.71","10.71","","","","10.71","Fee Schedule","","","","","10.71","Fee Schedule","101% of Medicare Fee Schedule","","","","10.71","Fee Schedule","","5.56","52","","","Percent of Total Billed Charges","neg_dollar:$5.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.21","86","","","Percent of Total Billed Charges","neg_dollar:$9.21","7.49","70","","","Percent of Total Billed Charges","neg_dollar:$7.49","5.56","52","","","Percent of Total Billed Charges","neg_dollar:$5.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.29;102% of Medicaid interim rate","8.03","75","","","Percent of Total Billed Charges","neg_dollar:$8.03","9.21","86","","","Percent of Total Billed Charges","neg_dollar:$9.21","7.49","70","","","Percent of Total Billed Charges","neg_dollar:$7.49","6.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.10;103.5% of Medicaid interim rate","10.71","150","","","Percent of Total Billed Charges","neg_dollar:$16.55;150% of Medicaid interim rate","8.56","80","","","Percent of Total Billed Charges","neg_dollar:$8.56;Percent of Total Billed Charges","9.85","92","","","Percent of Total Billed Charges","neg_dollar:$9.85","5.56","52","","","Percent of Total Billed Charges","neg_dollar:$5.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.56","52","","","Percent of Total Billed Charges","neg_dollar:$5.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","J0360","HCPCS","63323-614-00","NDC","636","RC","","Facility","Outpatient","1","ML","104.71","104.71","","","","5.00","Fee Schedule","","","","","52.00","Fee Schedule","101% of Medicare Fee Schedule","","","","6.00","Fee Schedule","","54.44","52","","","Percent of Total Billed Charges","neg_dollar:$54.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","104.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","104.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","90.05","86","","","Percent of Total Billed Charges","neg_dollar:$90.05","73.29","70","","","Percent of Total Billed Charges","neg_dollar:$73.29","54.44","52","","","Percent of Total Billed Charges","neg_dollar:$54.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","61.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$61.51;102% of Medicaid interim rate","78.53","75","","","Percent of Total Billed Charges","neg_dollar:$78.53","90.05","86","","","Percent of Total Billed Charges","neg_dollar:$90.05","73.29","70","","","Percent of Total Billed Charges","neg_dollar:$73.29","59.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.68;103.5% of Medicaid interim rate","104.71","150","","","Percent of Total Billed Charges","neg_dollar:$161.88;150% of Medicaid interim rate","83.76","80","","","Percent of Total Billed Charges","neg_dollar:$83.76;Percent of Total Billed Charges","96.33","92","","","Percent of Total Billed Charges","neg_dollar:$96.33","54.44","52","","","Percent of Total Billed Charges","neg_dollar:$54.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","54.44","52","","","Percent of Total Billed Charges","neg_dollar:$54.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","104.00",""
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","J0360","HCPCS","63323-614-00","NDC","636","RC","","Facility","Outpatient","1","ML","101.85","101.85","","","","5.00","Fee Schedule","","","","","52.00","Fee Schedule","101% of Medicare Fee Schedule","","","","6.00","Fee Schedule","","52.96","52","","","Percent of Total Billed Charges","neg_dollar:$52.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","101.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","101.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","87.59","86","","","Percent of Total Billed Charges","neg_dollar:$87.59","71.29","70","","","Percent of Total Billed Charges","neg_dollar:$71.29","52.96","52","","","Percent of Total Billed Charges","neg_dollar:$52.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","59.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.83;102% of Medicaid interim rate","76.38","75","","","Percent of Total Billed Charges","neg_dollar:$76.38","87.59","86","","","Percent of Total Billed Charges","neg_dollar:$87.59","71.29","70","","","Percent of Total Billed Charges","neg_dollar:$71.29","58.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$58.05;103.5% of Medicaid interim rate","101.85","150","","","Percent of Total Billed Charges","neg_dollar:$157.46;150% of Medicaid interim rate","81.48","80","","","Percent of Total Billed Charges","neg_dollar:$81.48;Percent of Total Billed Charges","93.70","92","","","Percent of Total Billed Charges","neg_dollar:$93.70","52.96","52","","","Percent of Total Billed Charges","neg_dollar:$52.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","52.96","52","","","Percent of Total Billed Charges","neg_dollar:$52.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","101.00",""
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","J0360","HCPCS","63323-614-01","NDC","250","RC","","Facility","Outpatient","1","ML","116.15","116.15","","","","5.00","Fee Schedule","","","","","52.00","Fee Schedule","","","","","6.00","Fee Schedule","","","52","","116.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","99.88","86","","","Percent of Total Billed Charges","neg_dollar:$99.88","81.30","70","","","Percent of Total Billed Charges","neg_dollar:$81.30","","52","","81.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","68.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.23;102% of Medicaid interim rate","87.11","75","","","Percent of Total Billed Charges","neg_dollar:$87.11","99.88","86","","","Percent of Total Billed Charges","neg_dollar:$99.88","81.30","70","","","Percent of Total Billed Charges","neg_dollar:$81.30","66.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.20;103.5% of Medicaid interim rate","116.15","150","","","Percent of Total Billed Charges","neg_dollar:$179.57;150% of Medicaid interim rate","92.92","80","","","Percent of Total Billed Charges","neg_dollar:$92.92;Percent of Total Billed Charges","106.85","92","","","Percent of Total Billed Charges","neg_dollar:$106.85","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","62.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","116.00",""
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","J0360","HCPCS","63323-614-00","NDC","636","RC","","Facility","Outpatient","1","ML","116.15","116.15","","","","5.00","Fee Schedule","","","","","52.00","Fee Schedule","101% of Medicare Fee Schedule","","","","6.00","Fee Schedule","","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","116.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","116.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","99.88","86","","","Percent of Total Billed Charges","neg_dollar:$99.88","81.30","70","","","Percent of Total Billed Charges","neg_dollar:$81.30","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;105% Medicare Outpatient Cost to Charge Ratio of 52%","68.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.23;102% of Medicaid interim rate","87.11","75","","","Percent of Total Billed Charges","neg_dollar:$87.11","99.88","86","","","Percent of Total Billed Charges","neg_dollar:$99.88","81.30","70","","","Percent of Total Billed Charges","neg_dollar:$81.30","66.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.20;103.5% of Medicaid interim rate","116.15","150","","","Percent of Total Billed Charges","neg_dollar:$179.57;150% of Medicaid interim rate","92.92","80","","","Percent of Total Billed Charges","neg_dollar:$92.92;Percent of Total Billed Charges","106.85","92","","","Percent of Total Billed Charges","neg_dollar:$106.85","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","116.00",""
"HYDRALAZINE HCL 20 MG/ML IJ SOLN","J0360","HCPCS","63323-614-01","NDC","636","RC","","Facility","Outpatient","1","ML","116.15","116.15","","","","5.00","Fee Schedule","","","","","52.00","Fee Schedule","101% of Medicare Fee Schedule","","","","6.00","Fee Schedule","","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","116.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","116.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","99.88","86","","","Percent of Total Billed Charges","neg_dollar:$99.88","81.30","70","","","Percent of Total Billed Charges","neg_dollar:$81.30","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;105% Medicare Outpatient Cost to Charge Ratio of 52%","68.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$68.23;102% of Medicaid interim rate","87.11","75","","","Percent of Total Billed Charges","neg_dollar:$87.11","99.88","86","","","Percent of Total Billed Charges","neg_dollar:$99.88","81.30","70","","","Percent of Total Billed Charges","neg_dollar:$81.30","66.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.20;103.5% of Medicaid interim rate","116.15","150","","","Percent of Total Billed Charges","neg_dollar:$179.57;150% of Medicaid interim rate","92.92","80","","","Percent of Total Billed Charges","neg_dollar:$92.92;Percent of Total Billed Charges","106.85","92","","","Percent of Total Billed Charges","neg_dollar:$106.85","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","60.39","52","","","Percent of Total Billed Charges","neg_dollar:$60.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","116.00",""
"AZITHROMYCIN 500 MG IV SOLR","J0456","HCPCS","63323-398-10","NDC","636","RC","","Facility","Outpatient","500","ME","94.50","94.50","","","","37.00","Fee Schedule","","","","","51.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","49.14","52","","","Percent of Total Billed Charges","neg_dollar:$49.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","94.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","94.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","81.27","86","","","Percent of Total Billed Charges","neg_dollar:$81.27","66.14","70","","","Percent of Total Billed Charges","neg_dollar:$66.14","49.14","52","","","Percent of Total Billed Charges","neg_dollar:$49.14;105% Medicare Outpatient Cost to Charge Ratio of 52%","55.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.51;102% of Medicaid interim rate","70.87","75","","","Percent of Total Billed Charges","neg_dollar:$70.87","81.27","86","","","Percent of Total Billed Charges","neg_dollar:$81.27","66.14","70","","","Percent of Total Billed Charges","neg_dollar:$66.14","53.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.86;103.5% of Medicaid interim rate","94.50","150","","","Percent of Total Billed Charges","neg_dollar:$146.10;150% of Medicaid interim rate","75.60","80","","","Percent of Total Billed Charges","neg_dollar:$75.60;Percent of Total Billed Charges","86.94","92","","","Percent of Total Billed Charges","neg_dollar:$86.94","49.14","52","","","Percent of Total Billed Charges","neg_dollar:$49.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","49.14","52","","","Percent of Total Billed Charges","neg_dollar:$49.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","94.00",""
"AZITHROMYCIN 500 MG IV SOLR","J0456","HCPCS","55150-174-10","NDC","250","RC","","Facility","Outpatient","500","ME","99.90","99.90","","","","37.00","Fee Schedule","","","","","51.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","99.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","51.94","52","","","Percent of Total Billed Charges","neg_dollar:$51.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.94","52","","","Percent of Total Billed Charges","neg_dollar:$51.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","85.91","86","","","Percent of Total Billed Charges","neg_dollar:$85.91","69.92","70","","","Percent of Total Billed Charges","neg_dollar:$69.92","","52","","79.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","58.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$58.69;102% of Medicaid interim rate","74.92","75","","","Percent of Total Billed Charges","neg_dollar:$74.92","85.91","86","","","Percent of Total Billed Charges","neg_dollar:$85.91","69.92","70","","","Percent of Total Billed Charges","neg_dollar:$69.92","56.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.94;103.5% of Medicaid interim rate","99.90","150","","","Percent of Total Billed Charges","neg_dollar:$154.45;150% of Medicaid interim rate","79.92","80","","","Percent of Total Billed Charges","neg_dollar:$79.92;Percent of Total Billed Charges","91.90","92","","","Percent of Total Billed Charges","neg_dollar:$91.90","51.94","52","","","Percent of Total Billed Charges","neg_dollar:$51.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","99.00",""
"AZITHROMYCIN 500 MG IV SOLR","J0456","HCPCS","63323-398-10","NDC","250","RC","","Facility","Outpatient","500","ME","94.50","94.50","","","","37.00","Fee Schedule","","","","","51.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","94.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","49.14","52","","","Percent of Total Billed Charges","neg_dollar:$49.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","49.14","52","","","Percent of Total Billed Charges","neg_dollar:$49.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","81.27","86","","","Percent of Total Billed Charges","neg_dollar:$81.27","66.14","70","","","Percent of Total Billed Charges","neg_dollar:$66.14","","52","","79.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","55.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.51;102% of Medicaid interim rate","70.87","75","","","Percent of Total Billed Charges","neg_dollar:$70.87","81.27","86","","","Percent of Total Billed Charges","neg_dollar:$81.27","66.14","70","","","Percent of Total Billed Charges","neg_dollar:$66.14","53.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.86;103.5% of Medicaid interim rate","94.50","150","","","Percent of Total Billed Charges","neg_dollar:$146.10;150% of Medicaid interim rate","75.60","80","","","Percent of Total Billed Charges","neg_dollar:$75.60;Percent of Total Billed Charges","86.94","92","","","Percent of Total Billed Charges","neg_dollar:$86.94","49.14","52","","","Percent of Total Billed Charges","neg_dollar:$49.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","94.00",""
"AZITHROMYCIN 500 MG IV SOLR","J0456","HCPCS","55150-174-10","NDC","636","RC","","Facility","Outpatient","500","ME","99.90","99.90","","","","37.00","Fee Schedule","","","","","51.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","51.94","52","","","Percent of Total Billed Charges","neg_dollar:$51.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","99.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","99.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","85.91","86","","","Percent of Total Billed Charges","neg_dollar:$85.91","69.92","70","","","Percent of Total Billed Charges","neg_dollar:$69.92","51.94","52","","","Percent of Total Billed Charges","neg_dollar:$51.94;105% Medicare Outpatient Cost to Charge Ratio of 52%","58.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$58.69;102% of Medicaid interim rate","74.92","75","","","Percent of Total Billed Charges","neg_dollar:$74.92","85.91","86","","","Percent of Total Billed Charges","neg_dollar:$85.91","69.92","70","","","Percent of Total Billed Charges","neg_dollar:$69.92","56.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.94;103.5% of Medicaid interim rate","99.90","150","","","Percent of Total Billed Charges","neg_dollar:$154.45;150% of Medicaid interim rate","79.92","80","","","Percent of Total Billed Charges","neg_dollar:$79.92;Percent of Total Billed Charges","91.90","92","","","Percent of Total Billed Charges","neg_dollar:$91.90","51.94","52","","","Percent of Total Billed Charges","neg_dollar:$51.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","51.94","52","","","Percent of Total Billed Charges","neg_dollar:$51.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","99.00",""
"ATROPINE SULFATE 0.4 MG/ML IV SOLN","J0461","HCPCS","00517-1004-25","NDC","636","RC","","Facility","Outpatient","1","UN","2.75","2.75","","","","2.75","Fee Schedule","","","","","2.75","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","1.43","52","","","Percent of Total Billed Charges","neg_dollar:$1.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.36","86","","","Percent of Total Billed Charges","neg_dollar:$2.36","1.92","70","","","Percent of Total Billed Charges","neg_dollar:$1.92","1.43","52","","","Percent of Total Billed Charges","neg_dollar:$1.43;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% of Medicaid interim rate","2.06","75","","","Percent of Total Billed Charges","neg_dollar:$2.06","2.36","86","","","Percent of Total Billed Charges","neg_dollar:$2.36","1.92","70","","","Percent of Total Billed Charges","neg_dollar:$1.92","1.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.56;103.5% of Medicaid interim rate","2.75","150","","","Percent of Total Billed Charges","neg_dollar:$4.25;150% of Medicaid interim rate","2.20","80","","","Percent of Total Billed Charges","neg_dollar:$2.20;Percent of Total Billed Charges","2.53","92","","","Percent of Total Billed Charges","neg_dollar:$2.53","1.43","52","","","Percent of Total Billed Charges","neg_dollar:$1.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.43","52","","","Percent of Total Billed Charges","neg_dollar:$1.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"ATROPINE SULFATE 1 MG/10ML IJ SOSY","J0461","HCPCS","76329-3340-1","NDC","250","RC","","Facility","Outpatient","1","UN","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ATROPINE SULFATE (PF) 1 MG/ML IJ SOLN","J0461","HCPCS","00517-1010-25","NDC","636","RC","","Facility","Outpatient","1","UN","1.12","1.12","","","","1.12","Fee Schedule","","","","","1.12","Fee Schedule","101% of Medicare Fee Schedule","","","","1.12","Fee Schedule","","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.66;102% of Medicaid interim rate","0.84","75","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;103.5% of Medicaid interim rate","1.12","150","","","Percent of Total Billed Charges","neg_dollar:$1.74;150% of Medicaid interim rate","0.90","80","","","Percent of Total Billed Charges","neg_dollar:$0.90;Percent of Total Billed Charges","1.03","92","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY","J0561","HCPCS","60793-701-10","NDC","636","RC","","Facility","Outpatient","1","UN","65.15","65.15","","","","65.15","Fee Schedule","","","","","65.15","Fee Schedule","101% of Medicare Fee Schedule","","","","65.15","Fee Schedule","","33.88","52","","","Percent of Total Billed Charges","neg_dollar:$33.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","65.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","65.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","56.03","86","","","Percent of Total Billed Charges","neg_dollar:$56.03","45.60","70","","","Percent of Total Billed Charges","neg_dollar:$45.60","33.88","52","","","Percent of Total Billed Charges","neg_dollar:$33.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","38.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$38.27;102% of Medicaid interim rate","48.86","75","","","Percent of Total Billed Charges","neg_dollar:$48.86","56.03","86","","","Percent of Total Billed Charges","neg_dollar:$56.03","45.60","70","","","Percent of Total Billed Charges","neg_dollar:$45.60","37.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.13;103.5% of Medicaid interim rate","65.15","150","","","Percent of Total Billed Charges","neg_dollar:$100.73;150% of Medicaid interim rate","52.12","80","","","Percent of Total Billed Charges","neg_dollar:$52.12;Percent of Total Billed Charges","59.94","92","","","Percent of Total Billed Charges","neg_dollar:$59.94","33.88","52","","","Percent of Total Billed Charges","neg_dollar:$33.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.88","52","","","Percent of Total Billed Charges","neg_dollar:$33.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","33.00","65.00",""
"PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY","J0561","HCPCS","60793-701-10","NDC","250","RC","","Facility","Outpatient","1","UN","65.15","65.15","","","","65.15","Fee Schedule","","","","","65.15","Fee Schedule","","","","","65.15","Fee Schedule","","","52","","65.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","33.88","52","","","Percent of Total Billed Charges","neg_dollar:$33.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.88","52","","","Percent of Total Billed Charges","neg_dollar:$33.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","56.03","86","","","Percent of Total Billed Charges","neg_dollar:$56.03","45.60","70","","","Percent of Total Billed Charges","neg_dollar:$45.60","","52","","65.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","38.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$38.27;102% of Medicaid interim rate","48.86","75","","","Percent of Total Billed Charges","neg_dollar:$48.86","56.03","86","","","Percent of Total Billed Charges","neg_dollar:$56.03","45.60","70","","","Percent of Total Billed Charges","neg_dollar:$45.60","37.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.13;103.5% of Medicaid interim rate","65.15","150","","","Percent of Total Billed Charges","neg_dollar:$100.73;150% of Medicaid interim rate","52.12","80","","","Percent of Total Billed Charges","neg_dollar:$52.12;Percent of Total Billed Charges","59.94","92","","","Percent of Total Billed Charges","neg_dollar:$59.94","33.88","52","","","Percent of Total Billed Charges","neg_dollar:$33.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","65.15","Fee Schedule","","33.00","65.00",""
"CALCIUM GLUCONATE 10 % IV SOLN","J0612","HCPCS","63323-360-01","NDC","636","RC","","Facility","Outpatient","1","UN","1.07","1.07","","","","1.07","Fee Schedule","","","","","1.07","Fee Schedule","101% of Medicare Fee Schedule","","","","1.07","Fee Schedule","","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% of Medicaid interim rate","0.80","75","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;103.5% of Medicaid interim rate","1.07","150","","","Percent of Total Billed Charges","neg_dollar:$1.66;150% of Medicaid interim rate","0.86","80","","","Percent of Total Billed Charges","neg_dollar:$0.86;Percent of Total Billed Charges","0.98","92","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CALCIUM GLUCONATE 10 % IV SOLN","J0612","HCPCS","63323-360-01","NDC","250","RC","","Facility","Outpatient","1","UN","1.07","1.07","","","","1.07","Fee Schedule","","","","","1.07","Fee Schedule","","","","","1.07","Fee Schedule","","","52","","1.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","","52","","1.07","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% of Medicaid interim rate","0.80","75","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;103.5% of Medicaid interim rate","1.07","150","","","Percent of Total Billed Charges","neg_dollar:$1.66;150% of Medicaid interim rate","0.86","80","","","Percent of Total Billed Charges","neg_dollar:$0.86;Percent of Total Billed Charges","0.98","92","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.07","Fee Schedule","","1.00","1.00",""
"METOPROLOL TARTRATE 5 MG/5ML IV SOLN","J0616","HCPCS","36000-033-10","NDC","636","RC","","Facility","Outpatient","5","ML","17.90","17.90","","","","17.90","Fee Schedule","","","","","17.90","Fee Schedule","101% of Medicare Fee Schedule","","","","17.90","Fee Schedule","","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.39","86","","","Percent of Total Billed Charges","neg_dollar:$15.39","12.52","70","","","Percent of Total Billed Charges","neg_dollar:$12.52","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.51;102% of Medicaid interim rate","13.42","75","","","Percent of Total Billed Charges","neg_dollar:$13.42","15.39","86","","","Percent of Total Billed Charges","neg_dollar:$15.39","12.52","70","","","Percent of Total Billed Charges","neg_dollar:$12.52","10.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.20;103.5% of Medicaid interim rate","17.90","150","","","Percent of Total Billed Charges","neg_dollar:$27.67;150% of Medicaid interim rate","14.32","80","","","Percent of Total Billed Charges","neg_dollar:$14.32;Percent of Total Billed Charges","16.46","92","","","Percent of Total Billed Charges","neg_dollar:$16.46","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","17.00",""
"METOPROLOL TARTRATE 5 MG/5ML IV SOLN","J0616","HCPCS","00409-1778-15","NDC","636","RC","","Facility","Outpatient","5","ML","18.02","18.02","","","","18.02","Fee Schedule","","","","","18.02","Fee Schedule","101% of Medicare Fee Schedule","","","","18.02","Fee Schedule","","9.37","52","","","Percent of Total Billed Charges","neg_dollar:$9.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","18.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","18.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.49","86","","","Percent of Total Billed Charges","neg_dollar:$15.49","12.61","70","","","Percent of Total Billed Charges","neg_dollar:$12.61","9.37","52","","","Percent of Total Billed Charges","neg_dollar:$9.37;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.58;102% of Medicaid interim rate","13.51","75","","","Percent of Total Billed Charges","neg_dollar:$13.51","15.49","86","","","Percent of Total Billed Charges","neg_dollar:$15.49","12.61","70","","","Percent of Total Billed Charges","neg_dollar:$12.61","10.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.27;103.5% of Medicaid interim rate","18.02","150","","","Percent of Total Billed Charges","neg_dollar:$27.85;150% of Medicaid interim rate","14.41","80","","","Percent of Total Billed Charges","neg_dollar:$14.41;Percent of Total Billed Charges","16.57","92","","","Percent of Total Billed Charges","neg_dollar:$16.57","9.37","52","","","Percent of Total Billed Charges","neg_dollar:$9.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.37","52","","","Percent of Total Billed Charges","neg_dollar:$9.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","18.00",""
"CASPOFUNGIN ACETATE 50 MG IV SOLR","J0637","HCPCS","25021-194-10","NDC","250","RC","","Facility","Outpatient","1","ME","22.55","22.55","","","","22.55","Fee Schedule","","","","","22.55","Fee Schedule","","","","","22.55","Fee Schedule","","","52","","22.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.72","52","","","Percent of Total Billed Charges","neg_dollar:$11.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.72","52","","","Percent of Total Billed Charges","neg_dollar:$11.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.39","86","","","Percent of Total Billed Charges","neg_dollar:$19.39","15.78","70","","","Percent of Total Billed Charges","neg_dollar:$15.78","","52","","22.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.24;102% of Medicaid interim rate","16.91","75","","","Percent of Total Billed Charges","neg_dollar:$16.91","19.39","86","","","Percent of Total Billed Charges","neg_dollar:$19.39","15.78","70","","","Percent of Total Billed Charges","neg_dollar:$15.78","12.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.85;103.5% of Medicaid interim rate","22.55","150","","","Percent of Total Billed Charges","neg_dollar:$34.86;150% of Medicaid interim rate","18.04","80","","","Percent of Total Billed Charges","neg_dollar:$18.04;Percent of Total Billed Charges","20.74","92","","","Percent of Total Billed Charges","neg_dollar:$20.74","11.72","52","","","Percent of Total Billed Charges","neg_dollar:$11.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","22.55","Fee Schedule","","11.00","22.00",""
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"BUPIVACAINE HCL (PF) 0.25 % IJ SOLN","J0665","HCPCS","55150-168-30","NDC","636","RC","","Facility","Outpatient","1","UN","1.09","1.09","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","101% of Medicare Fee Schedule","","","","1.09","Fee Schedule","","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.09","150","","","Percent of Total Billed Charges","neg_dollar:$1.68;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.00","92","","","Percent of Total Billed Charges","neg_dollar:$1","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BUPIVACAINE HCL (PF) 0.5 % IJ SOLN","J0665","HCPCS","55150-170-30","NDC","636","RC","","Facility","Outpatient","1","UN","0.41","0.41","","","","0.41","Fee Schedule","","","","","0.41","Fee Schedule","101% of Medicare Fee Schedule","","","","0.41","Fee Schedule","","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","86","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","70","","","Percent of Total Billed Charges","neg_dollar:$0.28","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.24;102% of Medicaid interim rate","0.31","75","","","Percent of Total Billed Charges","neg_dollar:$0.31","0.35","86","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","70","","","Percent of Total Billed Charges","neg_dollar:$0.28","0.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.23;103.5% of Medicaid interim rate","0.41","150","","","Percent of Total Billed Charges","neg_dollar:$0.63;150% of Medicaid interim rate","0.33","80","","","Percent of Total Billed Charges","neg_dollar:$0.33;Percent of Total Billed Charges","0.38","92","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
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"BUPIVACAINE LIPOSOME 1.3 % IJ SUSP","J0666","HCPCS","65250-133-04","NDC","636","RC","","Facility","Outpatient","1","UN","1.79","1.79","","","","1.79","Fee Schedule","","","","","1.79","Fee Schedule","101% of Medicare Fee Schedule","","","","1.79","Fee Schedule","","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.25","70","","","Percent of Total Billed Charges","neg_dollar:$1.25","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;102% of Medicaid interim rate","1.34","75","","","Percent of Total Billed Charges","neg_dollar:$1.34","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.25","70","","","Percent of Total Billed Charges","neg_dollar:$1.25","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;103.5% of Medicaid interim rate","1.79","150","","","Percent of Total Billed Charges","neg_dollar:$2.77;150% of Medicaid interim rate","1.43","80","","","Percent of Total Billed Charges","neg_dollar:$1.43;Percent of Total Billed Charges","1.65","92","","","Percent of Total Billed Charges","neg_dollar:$1.65","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BUPIVACAINE LIPOSOME 1.3 % IJ SUSP","J0666","HCPCS","65250-133-04","NDC","636","RC","","Facility","Outpatient","1","UN","3.96","3.96","","","","3.96","Fee Schedule","","","","","3.96","Fee Schedule","101% of Medicare Fee Schedule","","","","3.96","Fee Schedule","","2.06","52","","","Percent of Total Billed Charges","neg_dollar:$2.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.41","86","","","Percent of Total Billed Charges","neg_dollar:$3.41","2.77","70","","","Percent of Total Billed Charges","neg_dollar:$2.77","2.06","52","","","Percent of Total Billed Charges","neg_dollar:$2.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.33;102% of Medicaid interim rate","2.97","75","","","Percent of Total Billed Charges","neg_dollar:$2.97","3.41","86","","","Percent of Total Billed Charges","neg_dollar:$3.41","2.77","70","","","Percent of Total Billed Charges","neg_dollar:$2.77","2.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.26;103.5% of Medicaid interim rate","3.96","150","","","Percent of Total Billed Charges","neg_dollar:$6.13;150% of Medicaid interim rate","3.17","80","","","Percent of Total Billed Charges","neg_dollar:$3.17;Percent of Total Billed Charges","3.65","92","","","Percent of Total Billed Charges","neg_dollar:$3.65","2.06","52","","","Percent of Total Billed Charges","neg_dollar:$2.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.06","52","","","Percent of Total Billed Charges","neg_dollar:$2.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","3.00",""
"CEFAZOLIN SODIUM 1 G IJ SOLR","J0687","HCPCS","44567-707-25","NDC","636","RC","","Facility","Outpatient","1","GM","45.40","45.40","","","","45.40","Fee Schedule","","","","","45.40","Fee Schedule","101% of Medicare Fee Schedule","","","","45.40","Fee Schedule","","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","45.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","45.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","39.04","86","","","Percent of Total Billed Charges","neg_dollar:$39.04","31.77","70","","","Percent of Total Billed Charges","neg_dollar:$31.77","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","26.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.67;102% of Medicaid interim rate","34.05","75","","","Percent of Total Billed Charges","neg_dollar:$34.05","39.04","86","","","Percent of Total Billed Charges","neg_dollar:$39.04","31.77","70","","","Percent of Total Billed Charges","neg_dollar:$31.77","25.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.87;103.5% of Medicaid interim rate","45.40","150","","","Percent of Total Billed Charges","neg_dollar:$70.19;150% of Medicaid interim rate","36.32","80","","","Percent of Total Billed Charges","neg_dollar:$36.32;Percent of Total Billed Charges","41.76","92","","","Percent of Total Billed Charges","neg_dollar:$41.76","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.00","45.00",""
"CEFAZOLIN SODIUM-DEXTROSE 1-4 GM-%(50ML) IV SOLR","J0690","HCPCS","00264-3103-11","NDC","636","RC","","Facility","Outpatient","1","EA","56.87","56.87","","","","42.00","Fee Schedule","","","","","56.87","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","29.57","52","","","Percent of Total Billed Charges","neg_dollar:$29.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","56.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","56.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","48.91","86","","","Percent of Total Billed Charges","neg_dollar:$48.91","39.81","70","","","Percent of Total Billed Charges","neg_dollar:$39.81","29.57","52","","","Percent of Total Billed Charges","neg_dollar:$29.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","33.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.41;102% of Medicaid interim rate","42.65","75","","","Percent of Total Billed Charges","neg_dollar:$42.65","48.91","86","","","Percent of Total Billed Charges","neg_dollar:$48.91","39.81","70","","","Percent of Total Billed Charges","neg_dollar:$39.81","32.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.41;103.5% of Medicaid interim rate","56.87","150","","","Percent of Total Billed Charges","neg_dollar:$87.93;150% of Medicaid interim rate","45.50","80","","","Percent of Total Billed Charges","neg_dollar:$45.50;Percent of Total Billed Charges","52.32","92","","","Percent of Total Billed Charges","neg_dollar:$52.32","29.57","52","","","Percent of Total Billed Charges","neg_dollar:$29.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","29.57","52","","","Percent of Total Billed Charges","neg_dollar:$29.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","56.00",""
"CEFAZOLIN SODIUM-DEXTROSE 2-3 GM-%(50ML) IV SOLR","J0690","HCPCS","00264-3105-11","NDC","636","RC","","Facility","Outpatient","1","EA","29.26","29.26","","","","29.26","Fee Schedule","","","","","29.26","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","15.21","52","","","Percent of Total Billed Charges","neg_dollar:$15.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","29.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","29.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","25.16","86","","","Percent of Total Billed Charges","neg_dollar:$25.16","20.48","70","","","Percent of Total Billed Charges","neg_dollar:$20.48","15.21","52","","","Percent of Total Billed Charges","neg_dollar:$15.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","17.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.19;102% of Medicaid interim rate","21.94","75","","","Percent of Total Billed Charges","neg_dollar:$21.94","25.16","86","","","Percent of Total Billed Charges","neg_dollar:$25.16","20.48","70","","","Percent of Total Billed Charges","neg_dollar:$20.48","16.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.67;103.5% of Medicaid interim rate","29.26","150","","","Percent of Total Billed Charges","neg_dollar:$45.24;150% of Medicaid interim rate","23.41","80","","","Percent of Total Billed Charges","neg_dollar:$23.41;Percent of Total Billed Charges","26.92","92","","","Percent of Total Billed Charges","neg_dollar:$26.92","15.21","52","","","Percent of Total Billed Charges","neg_dollar:$15.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.21","52","","","Percent of Total Billed Charges","neg_dollar:$15.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","29.00",""
"CEFAZOLIN SODIUM-DEXTROSE 2-3 GM-%(50ML) IV SOLR","J0690","HCPCS","00264-3105-11","NDC","250","RC","","Facility","Outpatient","1","EA","29.26","29.26","","","","29.26","Fee Schedule","","","","","29.26","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","29.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.21","52","","","Percent of Total Billed Charges","neg_dollar:$15.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.21","52","","","Percent of Total Billed Charges","neg_dollar:$15.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","25.16","86","","","Percent of Total Billed Charges","neg_dollar:$25.16","20.48","70","","","Percent of Total Billed Charges","neg_dollar:$20.48","","52","","29.26","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","17.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.19;102% of Medicaid interim rate","21.94","75","","","Percent of Total Billed Charges","neg_dollar:$21.94","25.16","86","","","Percent of Total Billed Charges","neg_dollar:$25.16","20.48","70","","","Percent of Total Billed Charges","neg_dollar:$20.48","16.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.67;103.5% of Medicaid interim rate","29.26","150","","","Percent of Total Billed Charges","neg_dollar:$45.24;150% of Medicaid interim rate","23.41","80","","","Percent of Total Billed Charges","neg_dollar:$23.41;Percent of Total Billed Charges","26.92","92","","","Percent of Total Billed Charges","neg_dollar:$26.92","15.21","52","","","Percent of Total Billed Charges","neg_dollar:$15.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","29.26","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","29.00",""
"CEFEPIME HCL 1 G IJ SOLR","J0692","HCPCS","44567-240-10","NDC","636","RC","","Facility","Outpatient","1","UN","49.45","49.45","","","","36.00","Fee Schedule","","","","","49.45","Fee Schedule","101% of Medicare Fee Schedule","","","","39.00","Fee Schedule","","25.71","52","","","Percent of Total Billed Charges","neg_dollar:$25.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","49.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","49.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","42.52","86","","","Percent of Total Billed Charges","neg_dollar:$42.52","34.61","70","","","Percent of Total Billed Charges","neg_dollar:$34.61","25.71","52","","","Percent of Total Billed Charges","neg_dollar:$25.71;105% Medicare Outpatient Cost to Charge Ratio of 52%","29.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.05;102% of Medicaid interim rate","37.08","75","","","Percent of Total Billed Charges","neg_dollar:$37.08","42.52","86","","","Percent of Total Billed Charges","neg_dollar:$42.52","34.61","70","","","Percent of Total Billed Charges","neg_dollar:$34.61","28.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.18;103.5% of Medicaid interim rate","49.45","150","","","Percent of Total Billed Charges","neg_dollar:$76.45;150% of Medicaid interim rate","39.56","80","","","Percent of Total Billed Charges","neg_dollar:$39.56;Percent of Total Billed Charges","45.49","92","","","Percent of Total Billed Charges","neg_dollar:$45.49","25.71","52","","","Percent of Total Billed Charges","neg_dollar:$25.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","25.71","52","","","Percent of Total Billed Charges","neg_dollar:$25.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","25.00","49.00",""
"CEFEPIME HCL 1 G IJ SOLR","J0692","HCPCS","44567-240-10","NDC","250","RC","","Facility","Outpatient","1","UN","49.45","49.45","","","","36.00","Fee Schedule","","","","","49.45","Fee Schedule","","","","","39.00","Fee Schedule","","","52","","49.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","25.71","52","","","Percent of Total Billed Charges","neg_dollar:$25.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","25.71","52","","","Percent of Total Billed Charges","neg_dollar:$25.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","42.52","86","","","Percent of Total Billed Charges","neg_dollar:$42.52","34.61","70","","","Percent of Total Billed Charges","neg_dollar:$34.61","","52","","49.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","29.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.05;102% of Medicaid interim rate","37.08","75","","","Percent of Total Billed Charges","neg_dollar:$37.08","42.52","86","","","Percent of Total Billed Charges","neg_dollar:$42.52","34.61","70","","","Percent of Total Billed Charges","neg_dollar:$34.61","28.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.18;103.5% of Medicaid interim rate","49.45","150","","","Percent of Total Billed Charges","neg_dollar:$76.45;150% of Medicaid interim rate","39.56","80","","","Percent of Total Billed Charges","neg_dollar:$39.56;Percent of Total Billed Charges","45.49","92","","","Percent of Total Billed Charges","neg_dollar:$45.49","25.71","52","","","Percent of Total Billed Charges","neg_dollar:$25.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","49.45","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","25.00","49.00",""
"CEFEPIME HCL 2 G IV SOLR","J0692","HCPCS","44567-241-10","NDC","250","RC","","Facility","Outpatient","2","UN","26.77","26.77","","","","26.77","Fee Schedule","","","","","26.77","Fee Schedule","","","","","26.77","Fee Schedule","","","52","","26.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.92","52","","","Percent of Total Billed Charges","neg_dollar:$13.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.92","52","","","Percent of Total Billed Charges","neg_dollar:$13.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.02","86","","","Percent of Total Billed Charges","neg_dollar:$23.02","18.74","70","","","Percent of Total Billed Charges","neg_dollar:$18.74","","52","","26.77","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","15.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.73;102% of Medicaid interim rate","20.08","75","","","Percent of Total Billed Charges","neg_dollar:$20.08","23.02","86","","","Percent of Total Billed Charges","neg_dollar:$23.02","18.74","70","","","Percent of Total Billed Charges","neg_dollar:$18.74","15.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.26;103.5% of Medicaid interim rate","26.77","150","","","Percent of Total Billed Charges","neg_dollar:$41.39;150% of Medicaid interim rate","21.42","80","","","Percent of Total Billed Charges","neg_dollar:$21.42;Percent of Total Billed Charges","24.63","92","","","Percent of Total Billed Charges","neg_dollar:$24.63","13.92","52","","","Percent of Total Billed Charges","neg_dollar:$13.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","26.77","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","26.00",""
"CEFEPIME HCL 2 G IV SOLR","J0692","HCPCS","00409-9735-01","NDC","636","RC","","Facility","Outpatient","2","UN","26.90","26.90","","","","26.90","Fee Schedule","","","","","26.90","Fee Schedule","101% of Medicare Fee Schedule","","","","26.90","Fee Schedule","","13.98","52","","","Percent of Total Billed Charges","neg_dollar:$13.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","23.13","86","","","Percent of Total Billed Charges","neg_dollar:$23.13","18.83","70","","","Percent of Total Billed Charges","neg_dollar:$18.83","13.98","52","","","Percent of Total Billed Charges","neg_dollar:$13.98;105% Medicare Outpatient Cost to Charge Ratio of 52%","15.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.80;102% of Medicaid interim rate","20.17","75","","","Percent of Total Billed Charges","neg_dollar:$20.17","23.13","86","","","Percent of Total Billed Charges","neg_dollar:$23.13","18.83","70","","","Percent of Total Billed Charges","neg_dollar:$18.83","15.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.33;103.5% of Medicaid interim rate","26.90","150","","","Percent of Total Billed Charges","neg_dollar:$41.58;150% of Medicaid interim rate","21.52","80","","","Percent of Total Billed Charges","neg_dollar:$21.52;Percent of Total Billed Charges","24.74","92","","","Percent of Total Billed Charges","neg_dollar:$24.74","13.98","52","","","Percent of Total Billed Charges","neg_dollar:$13.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.98","52","","","Percent of Total Billed Charges","neg_dollar:$13.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","26.00",""
"CEFEPIME HCL 2 G IV SOLR","J0692","HCPCS","00409-9735-01","NDC","250","RC","","Facility","Outpatient","2","UN","26.90","26.90","","","","26.90","Fee Schedule","","","","","26.90","Fee Schedule","","","","","26.90","Fee Schedule","","","52","","26.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.98","52","","","Percent of Total Billed Charges","neg_dollar:$13.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.98","52","","","Percent of Total Billed Charges","neg_dollar:$13.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.13","86","","","Percent of Total Billed Charges","neg_dollar:$23.13","18.83","70","","","Percent of Total Billed Charges","neg_dollar:$18.83","","52","","26.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","15.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.80;102% of Medicaid interim rate","20.17","75","","","Percent of Total Billed Charges","neg_dollar:$20.17","23.13","86","","","Percent of Total Billed Charges","neg_dollar:$23.13","18.83","70","","","Percent of Total Billed Charges","neg_dollar:$18.83","15.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.33;103.5% of Medicaid interim rate","26.90","150","","","Percent of Total Billed Charges","neg_dollar:$41.58;150% of Medicaid interim rate","21.52","80","","","Percent of Total Billed Charges","neg_dollar:$21.52;Percent of Total Billed Charges","24.74","92","","","Percent of Total Billed Charges","neg_dollar:$24.74","13.98","52","","","Percent of Total Billed Charges","neg_dollar:$13.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","26.90","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","26.00",""
"CEFEPIME HCL 2 G IV SOLR","J0692","HCPCS","44567-241-10","NDC","636","RC","","Facility","Outpatient","2","UN","26.77","26.77","","","","26.77","Fee Schedule","","","","","26.77","Fee Schedule","101% of Medicare Fee Schedule","","","","26.77","Fee Schedule","","13.92","52","","","Percent of Total Billed Charges","neg_dollar:$13.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","23.02","86","","","Percent of Total Billed Charges","neg_dollar:$23.02","18.74","70","","","Percent of Total Billed Charges","neg_dollar:$18.74","13.92","52","","","Percent of Total Billed Charges","neg_dollar:$13.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","15.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.73;102% of Medicaid interim rate","20.08","75","","","Percent of Total Billed Charges","neg_dollar:$20.08","23.02","86","","","Percent of Total Billed Charges","neg_dollar:$23.02","18.74","70","","","Percent of Total Billed Charges","neg_dollar:$18.74","15.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.26;103.5% of Medicaid interim rate","26.77","150","","","Percent of Total Billed Charges","neg_dollar:$41.39;150% of Medicaid interim rate","21.42","80","","","Percent of Total Billed Charges","neg_dollar:$21.42;Percent of Total Billed Charges","24.63","92","","","Percent of Total Billed Charges","neg_dollar:$24.63","13.92","52","","","Percent of Total Billed Charges","neg_dollar:$13.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.92","52","","","Percent of Total Billed Charges","neg_dollar:$13.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","26.00",""
"CEFTRIAXONE SODIUM 1 G IJ SOLR","J0696","HCPCS","00143-9857-25","NDC","636","RC","","Facility","Outpatient","1","EA","22.87","22.87","","","","4.00","Fee Schedule","","","","","22.87","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","11.89","52","","","Percent of Total Billed Charges","neg_dollar:$11.89;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","22.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","22.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","19.67","86","","","Percent of Total Billed Charges","neg_dollar:$19.67","16.01","70","","","Percent of Total Billed Charges","neg_dollar:$16.01","11.89","52","","","Percent of Total Billed Charges","neg_dollar:$11.89;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.43;102% of Medicaid interim rate","17.15","75","","","Percent of Total Billed Charges","neg_dollar:$17.15","19.67","86","","","Percent of Total Billed Charges","neg_dollar:$19.67","16.01","70","","","Percent of Total Billed Charges","neg_dollar:$16.01","13.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.03;103.5% of Medicaid interim rate","22.87","150","","","Percent of Total Billed Charges","neg_dollar:$35.36;150% of Medicaid interim rate","18.30","80","","","Percent of Total Billed Charges","neg_dollar:$18.30;Percent of Total Billed Charges","21.04","92","","","Percent of Total Billed Charges","neg_dollar:$21.04","11.89","52","","","Percent of Total Billed Charges","neg_dollar:$11.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.89","52","","","Percent of Total Billed Charges","neg_dollar:$11.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","22.00",""
"CEFTRIAXONE SODIUM 1 G IJ SOLR","J0696","HCPCS","00143-9857-01","NDC","636","RC","","Facility","Outpatient","1","UN","20.43","20.43","","","","4.00","Fee Schedule","","","","","20.43","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","10.62","52","","","Percent of Total Billed Charges","neg_dollar:$10.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.57","86","","","Percent of Total Billed Charges","neg_dollar:$17.57","14.30","70","","","Percent of Total Billed Charges","neg_dollar:$14.30","10.62","52","","","Percent of Total Billed Charges","neg_dollar:$10.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$12;102% of Medicaid interim rate","15.32","75","","","Percent of Total Billed Charges","neg_dollar:$15.32","17.57","86","","","Percent of Total Billed Charges","neg_dollar:$17.57","14.30","70","","","Percent of Total Billed Charges","neg_dollar:$14.30","11.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.64;103.5% of Medicaid interim rate","20.43","150","","","Percent of Total Billed Charges","neg_dollar:$31.59;150% of Medicaid interim rate","16.34","80","","","Percent of Total Billed Charges","neg_dollar:$16.34;Percent of Total Billed Charges","18.80","92","","","Percent of Total Billed Charges","neg_dollar:$18.80","10.62","52","","","Percent of Total Billed Charges","neg_dollar:$10.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.62","52","","","Percent of Total Billed Charges","neg_dollar:$10.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","20.00",""
"CEFTRIAXONE SODIUM 1 G IJ SOLR","J0696","HCPCS","00143-9857-01","NDC","250","RC","","Facility","Outpatient","1","UN","11.93","11.93","","","","4.00","Fee Schedule","","","","","11.93","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","11.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.20","52","","","Percent of Total Billed Charges","neg_dollar:$6.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.20","52","","","Percent of Total Billed Charges","neg_dollar:$6.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.26","86","","","Percent of Total Billed Charges","neg_dollar:$10.26","8.35","70","","","Percent of Total Billed Charges","neg_dollar:$8.35","","52","","11.93","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.01;102% of Medicaid interim rate","8.95","75","","","Percent of Total Billed Charges","neg_dollar:$8.95","10.26","86","","","Percent of Total Billed Charges","neg_dollar:$10.26","8.35","70","","","Percent of Total Billed Charges","neg_dollar:$8.35","6.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.80;103.5% of Medicaid interim rate","11.93","150","","","Percent of Total Billed Charges","neg_dollar:$18.45;150% of Medicaid interim rate","9.55","80","","","Percent of Total Billed Charges","neg_dollar:$9.55;Percent of Total Billed Charges","10.98","92","","","Percent of Total Billed Charges","neg_dollar:$10.98","6.20","52","","","Percent of Total Billed Charges","neg_dollar:$6.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","11.93","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","11.00",""
"CEFTRIAXONE SODIUM-DEXTROSE 1-3.74 GM-%(50ML) IV SOLR","J0696","HCPCS","00264-3153-11","NDC","636","RC","","Facility","Outpatient","1","UN","31.72","31.72","","","","4.00","Fee Schedule","","","","","31.72","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","16.49","52","","","Percent of Total Billed Charges","neg_dollar:$16.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","27.28","86","","","Percent of Total Billed Charges","neg_dollar:$27.28","22.20","70","","","Percent of Total Billed Charges","neg_dollar:$22.20","16.49","52","","","Percent of Total Billed Charges","neg_dollar:$16.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","18.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.63;102% of Medicaid interim rate","23.79","75","","","Percent of Total Billed Charges","neg_dollar:$23.79","27.28","86","","","Percent of Total Billed Charges","neg_dollar:$27.28","22.20","70","","","Percent of Total Billed Charges","neg_dollar:$22.20","18.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.08;103.5% of Medicaid interim rate","31.72","150","","","Percent of Total Billed Charges","neg_dollar:$49.04;150% of Medicaid interim rate","25.38","80","","","Percent of Total Billed Charges","neg_dollar:$25.38;Percent of Total Billed Charges","29.18","92","","","Percent of Total Billed Charges","neg_dollar:$29.18","16.49","52","","","Percent of Total Billed Charges","neg_dollar:$16.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.49","52","","","Percent of Total Billed Charges","neg_dollar:$16.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","31.00",""
"CEFTRIAXONE SODIUM-DEXTROSE 1-3.74 GM-%(50ML) IV SOLR","J0696","HCPCS","00264-3153-11","NDC","250","RC","","Facility","Outpatient","1","UN","31.72","31.72","","","","4.00","Fee Schedule","","","","","31.72","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","31.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.49","52","","","Percent of Total Billed Charges","neg_dollar:$16.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.49","52","","","Percent of Total Billed Charges","neg_dollar:$16.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.28","86","","","Percent of Total Billed Charges","neg_dollar:$27.28","22.20","70","","","Percent of Total Billed Charges","neg_dollar:$22.20","","52","","31.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","18.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.63;102% of Medicaid interim rate","23.79","75","","","Percent of Total Billed Charges","neg_dollar:$23.79","27.28","86","","","Percent of Total Billed Charges","neg_dollar:$27.28","22.20","70","","","Percent of Total Billed Charges","neg_dollar:$22.20","18.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.08;103.5% of Medicaid interim rate","31.72","150","","","Percent of Total Billed Charges","neg_dollar:$49.04;150% of Medicaid interim rate","25.38","80","","","Percent of Total Billed Charges","neg_dollar:$25.38;Percent of Total Billed Charges","29.18","92","","","Percent of Total Billed Charges","neg_dollar:$29.18","16.49","52","","","Percent of Total Billed Charges","neg_dollar:$16.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","31.72","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","31.00",""
"CEFTRIAXONE SODIUM 2 G IV SOLR","J0696","HCPCS","00409-7336-04","NDC","636","RC","","Facility","Outpatient","2","UN","12.93","12.93","","","","4.00","Fee Schedule","","","","","12.93","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","6.72","52","","","Percent of Total Billed Charges","neg_dollar:$6.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.12","86","","","Percent of Total Billed Charges","neg_dollar:$11.12","9.05","70","","","Percent of Total Billed Charges","neg_dollar:$9.05","6.72","52","","","Percent of Total Billed Charges","neg_dollar:$6.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.59;102% of Medicaid interim rate","9.69","75","","","Percent of Total Billed Charges","neg_dollar:$9.69","11.12","86","","","Percent of Total Billed Charges","neg_dollar:$11.12","9.05","70","","","Percent of Total Billed Charges","neg_dollar:$9.05","7.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.37;103.5% of Medicaid interim rate","12.93","150","","","Percent of Total Billed Charges","neg_dollar:$19.99;150% of Medicaid interim rate","10.34","80","","","Percent of Total Billed Charges","neg_dollar:$10.34;Percent of Total Billed Charges","11.89","92","","","Percent of Total Billed Charges","neg_dollar:$11.89","6.72","52","","","Percent of Total Billed Charges","neg_dollar:$6.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.72","52","","","Percent of Total Billed Charges","neg_dollar:$6.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","12.00",""
"CEFTRIAXONE SODIUM 2 G IJ SOLR","J0696","HCPCS","00143-9856-01","NDC","250","RC","","Facility","Outpatient","2","UN","11.68","11.68","","","","4.00","Fee Schedule","","","","","11.68","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","11.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.07","52","","","Percent of Total Billed Charges","neg_dollar:$6.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.07","52","","","Percent of Total Billed Charges","neg_dollar:$6.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.05","86","","","Percent of Total Billed Charges","neg_dollar:$10.05","8.18","70","","","Percent of Total Billed Charges","neg_dollar:$8.18","","52","","11.68","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.86;102% of Medicaid interim rate","8.76","75","","","Percent of Total Billed Charges","neg_dollar:$8.76","10.05","86","","","Percent of Total Billed Charges","neg_dollar:$10.05","8.18","70","","","Percent of Total Billed Charges","neg_dollar:$8.18","6.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.66;103.5% of Medicaid interim rate","11.68","150","","","Percent of Total Billed Charges","neg_dollar:$18.06;150% of Medicaid interim rate","9.35","80","","","Percent of Total Billed Charges","neg_dollar:$9.35;Percent of Total Billed Charges","10.75","92","","","Percent of Total Billed Charges","neg_dollar:$10.75","6.07","52","","","Percent of Total Billed Charges","neg_dollar:$6.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","11.68","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","11.00",""
"CEFTRIAXONE SODIUM 2 G IJ SOLR","J0696","HCPCS","00143-9856-25","NDC","250","RC","","Facility","Outpatient","2","UN","11.68","11.68","","","","4.00","Fee Schedule","","","","","11.68","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","11.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.07","52","","","Percent of Total Billed Charges","neg_dollar:$6.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.07","52","","","Percent of Total Billed Charges","neg_dollar:$6.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.05","86","","","Percent of Total Billed Charges","neg_dollar:$10.05","8.18","70","","","Percent of Total Billed Charges","neg_dollar:$8.18","","52","","11.68","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.86;102% of Medicaid interim rate","8.76","75","","","Percent of Total Billed Charges","neg_dollar:$8.76","10.05","86","","","Percent of Total Billed Charges","neg_dollar:$10.05","8.18","70","","","Percent of Total Billed Charges","neg_dollar:$8.18","6.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.66;103.5% of Medicaid interim rate","11.68","150","","","Percent of Total Billed Charges","neg_dollar:$18.06;150% of Medicaid interim rate","9.35","80","","","Percent of Total Billed Charges","neg_dollar:$9.35;Percent of Total Billed Charges","10.75","92","","","Percent of Total Billed Charges","neg_dollar:$10.75","6.07","52","","","Percent of Total Billed Charges","neg_dollar:$6.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","11.68","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","11.00",""
"CEFTRIAXONE SODIUM-DEXTROSE 2-2.22 GM-%(50ML) IV SOLR","J0696","HCPCS","00264-3155-11","NDC","250","RC","","Facility","Outpatient","1","UN","17.50","17.50","","","","4.00","Fee Schedule","","","","","17.50","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","17.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.10","52","","","Percent of Total Billed Charges","neg_dollar:$9.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.10","52","","","Percent of Total Billed Charges","neg_dollar:$9.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.04","86","","","Percent of Total Billed Charges","neg_dollar:$15.04","12.25","70","","","Percent of Total Billed Charges","neg_dollar:$12.25","","52","","17.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.28;102% of Medicaid interim rate","13.12","75","","","Percent of Total Billed Charges","neg_dollar:$13.12","15.04","86","","","Percent of Total Billed Charges","neg_dollar:$15.04","12.25","70","","","Percent of Total Billed Charges","neg_dollar:$12.25","9.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.97;103.5% of Medicaid interim rate","17.50","150","","","Percent of Total Billed Charges","neg_dollar:$27.05;150% of Medicaid interim rate","14.00","80","","","Percent of Total Billed Charges","neg_dollar:$14;Percent of Total Billed Charges","16.10","92","","","Percent of Total Billed Charges","neg_dollar:$16.10","9.10","52","","","Percent of Total Billed Charges","neg_dollar:$9.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","17.50","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","17.00",""
"CEFTRIAXONE SODIUM-DEXTROSE 2-2.22 GM-%(50ML) IV SOLR","J0696","HCPCS","00264-3155-11","NDC","636","RC","","Facility","Outpatient","1","UN","17.50","17.50","","","","4.00","Fee Schedule","","","","","17.50","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","9.10","52","","","Percent of Total Billed Charges","neg_dollar:$9.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.04","86","","","Percent of Total Billed Charges","neg_dollar:$15.04","12.25","70","","","Percent of Total Billed Charges","neg_dollar:$12.25","9.10","52","","","Percent of Total Billed Charges","neg_dollar:$9.10;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.28;102% of Medicaid interim rate","13.12","75","","","Percent of Total Billed Charges","neg_dollar:$13.12","15.04","86","","","Percent of Total Billed Charges","neg_dollar:$15.04","12.25","70","","","Percent of Total Billed Charges","neg_dollar:$12.25","9.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.97;103.5% of Medicaid interim rate","17.50","150","","","Percent of Total Billed Charges","neg_dollar:$27.05;150% of Medicaid interim rate","14.00","80","","","Percent of Total Billed Charges","neg_dollar:$14;Percent of Total Billed Charges","16.10","92","","","Percent of Total Billed Charges","neg_dollar:$16.10","9.10","52","","","Percent of Total Billed Charges","neg_dollar:$9.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.10","52","","","Percent of Total Billed Charges","neg_dollar:$9.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","17.00",""
"CEFTRIAXONE SODIUM 500 MG IJ SOLR","J0696","HCPCS","60505-6152-1","NDC","636","RC","","Facility","Outpatient","1","UN","46","46.00","","","","4.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","46.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","46.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","39.56","86","","","Percent of Total Billed Charges","neg_dollar:$39.56","32.19","70","","","Percent of Total Billed Charges","neg_dollar:$32.19","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","27.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.02;102% of Medicaid interim rate","34.50","75","","","Percent of Total Billed Charges","neg_dollar:$34.50","39.56","86","","","Percent of Total Billed Charges","neg_dollar:$39.56","32.19","70","","","Percent of Total Billed Charges","neg_dollar:$32.19","26.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.22;103.5% of Medicaid interim rate","46.00","150","","","Percent of Total Billed Charges","neg_dollar:$71.11;150% of Medicaid interim rate","36.80","80","","","Percent of Total Billed Charges","neg_dollar:$36.80;Percent of Total Billed Charges","42.32","92","","","Percent of Total Billed Charges","neg_dollar:$42.32","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.92","52","","","Percent of Total Billed Charges","neg_dollar:$23.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","46.00",""
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","J0736","HCPCS","00781-3289-91","NDC","250","RC","","Facility","Outpatient","50","ML","55.60","55.60","","","","55.60","Fee Schedule","","","","","55.60","Fee Schedule","","","","","55.60","Fee Schedule","","","52","","55.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.91","52","","","Percent of Total Billed Charges","neg_dollar:$28.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.91","52","","","Percent of Total Billed Charges","neg_dollar:$28.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.81","86","","","Percent of Total Billed Charges","neg_dollar:$47.81","38.92","70","","","Percent of Total Billed Charges","neg_dollar:$38.92","","52","","55.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","32.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.66;102% of Medicaid interim rate","41.70","75","","","Percent of Total Billed Charges","neg_dollar:$41.70","47.81","86","","","Percent of Total Billed Charges","neg_dollar:$47.81","38.92","70","","","Percent of Total Billed Charges","neg_dollar:$38.92","31.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.69;103.5% of Medicaid interim rate","55.60","150","","","Percent of Total Billed Charges","neg_dollar:$85.96;150% of Medicaid interim rate","44.48","80","","","Percent of Total Billed Charges","neg_dollar:$44.48;Percent of Total Billed Charges","51.15","92","","","Percent of Total Billed Charges","neg_dollar:$51.15","28.91","52","","","Percent of Total Billed Charges","neg_dollar:$28.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.60","Fee Schedule","","28.00","55.00",""
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","J0736","HCPCS","00781-3289-91","NDC","636","RC","","Facility","Outpatient","50","ML","55.60","55.60","","","","55.60","Fee Schedule","","","","","55.60","Fee Schedule","101% of Medicare Fee Schedule","","","","55.60","Fee Schedule","","28.91","52","","","Percent of Total Billed Charges","neg_dollar:$28.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","55.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","55.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.81","86","","","Percent of Total Billed Charges","neg_dollar:$47.81","38.92","70","","","Percent of Total Billed Charges","neg_dollar:$38.92","28.91","52","","","Percent of Total Billed Charges","neg_dollar:$28.91;105% Medicare Outpatient Cost to Charge Ratio of 52%","32.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.66;102% of Medicaid interim rate","41.70","75","","","Percent of Total Billed Charges","neg_dollar:$41.70","47.81","86","","","Percent of Total Billed Charges","neg_dollar:$47.81","38.92","70","","","Percent of Total Billed Charges","neg_dollar:$38.92","31.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.69;103.5% of Medicaid interim rate","55.60","150","","","Percent of Total Billed Charges","neg_dollar:$85.96;150% of Medicaid interim rate","44.48","80","","","Percent of Total Billed Charges","neg_dollar:$44.48;Percent of Total Billed Charges","51.15","92","","","Percent of Total Billed Charges","neg_dollar:$51.15","28.91","52","","","Percent of Total Billed Charges","neg_dollar:$28.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","28.91","52","","","Percent of Total Billed Charges","neg_dollar:$28.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","28.00","55.00",""
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","J0737","HCPCS","00338-3612-50","NDC","636","RC","","Facility","Outpatient","50","ML","54.45","54.45","","","","40.00","Fee Schedule","","","","","54.45","Fee Schedule","101% of Medicare Fee Schedule","","","","9.00","Fee Schedule","","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","54.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","54.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.82","86","","","Percent of Total Billed Charges","neg_dollar:$46.82","38.11","70","","","Percent of Total Billed Charges","neg_dollar:$38.11","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;105% Medicare Outpatient Cost to Charge Ratio of 52%","31.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.98;102% of Medicaid interim rate","40.83","75","","","Percent of Total Billed Charges","neg_dollar:$40.83","46.82","86","","","Percent of Total Billed Charges","neg_dollar:$46.82","38.11","70","","","Percent of Total Billed Charges","neg_dollar:$38.11","31.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.03;103.5% of Medicaid interim rate","54.45","150","","","Percent of Total Billed Charges","neg_dollar:$84.18;150% of Medicaid interim rate","43.56","80","","","Percent of Total Billed Charges","neg_dollar:$43.56;Percent of Total Billed Charges","50.09","92","","","Percent of Total Billed Charges","neg_dollar:$50.09","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","54.00",""
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","J0737","HCPCS","00338-3612-24","NDC","250","RC","","Facility","Outpatient","50","ML","54.45","54.45","","","","40.00","Fee Schedule","","","","","54.45","Fee Schedule","","","","","9.00","Fee Schedule","","","52","","54.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.82","86","","","Percent of Total Billed Charges","neg_dollar:$46.82","38.11","70","","","Percent of Total Billed Charges","neg_dollar:$38.11","","52","","54.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","31.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.98;102% of Medicaid interim rate","40.83","75","","","Percent of Total Billed Charges","neg_dollar:$40.83","46.82","86","","","Percent of Total Billed Charges","neg_dollar:$46.82","38.11","70","","","Percent of Total Billed Charges","neg_dollar:$38.11","31.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.03;103.5% of Medicaid interim rate","54.45","150","","","Percent of Total Billed Charges","neg_dollar:$84.18;150% of Medicaid interim rate","43.56","80","","","Percent of Total Billed Charges","neg_dollar:$43.56;Percent of Total Billed Charges","50.09","92","","","Percent of Total Billed Charges","neg_dollar:$50.09","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.45","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","54.00",""
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","J0737","HCPCS","00338-3612-50","NDC","250","RC","","Facility","Outpatient","50","ML","54.45","54.45","","","","40.00","Fee Schedule","","","","","54.45","Fee Schedule","","","","","9.00","Fee Schedule","","","52","","54.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.82","86","","","Percent of Total Billed Charges","neg_dollar:$46.82","38.11","70","","","Percent of Total Billed Charges","neg_dollar:$38.11","","52","","54.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","31.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.98;102% of Medicaid interim rate","40.83","75","","","Percent of Total Billed Charges","neg_dollar:$40.83","46.82","86","","","Percent of Total Billed Charges","neg_dollar:$46.82","38.11","70","","","Percent of Total Billed Charges","neg_dollar:$38.11","31.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.03;103.5% of Medicaid interim rate","54.45","150","","","Percent of Total Billed Charges","neg_dollar:$84.18;150% of Medicaid interim rate","43.56","80","","","Percent of Total Billed Charges","neg_dollar:$43.56;Percent of Total Billed Charges","50.09","92","","","Percent of Total Billed Charges","neg_dollar:$50.09","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.45","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","54.00",""
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN","J0737","HCPCS","00338-3616-50","NDC","250","RC","","Facility","Outpatient","50","ML","54.45","54.45","","","","40.00","Fee Schedule","","","","","54.45","Fee Schedule","","","","","9.00","Fee Schedule","","","52","","54.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.82","86","","","Percent of Total Billed Charges","neg_dollar:$46.82","38.11","70","","","Percent of Total Billed Charges","neg_dollar:$38.11","","52","","54.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","31.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.98;102% of Medicaid interim rate","40.83","75","","","Percent of Total Billed Charges","neg_dollar:$40.83","46.82","86","","","Percent of Total Billed Charges","neg_dollar:$46.82","38.11","70","","","Percent of Total Billed Charges","neg_dollar:$38.11","31.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.03;103.5% of Medicaid interim rate","54.45","150","","","Percent of Total Billed Charges","neg_dollar:$84.18;150% of Medicaid interim rate","43.56","80","","","Percent of Total Billed Charges","neg_dollar:$43.56;Percent of Total Billed Charges","50.09","92","","","Percent of Total Billed Charges","neg_dollar:$50.09","28.31","52","","","Percent of Total Billed Charges","neg_dollar:$28.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.45","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","54.00",""
"CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN","J0744","HCPCS","00409-3300-01","NDC","636","RC","","Facility","Outpatient","50","ML","49.05","49.05","","","","35.00","Fee Schedule","","","","","48.00","Fee Schedule","101% of Medicare Fee Schedule","","","","4.00","Fee Schedule","","25.50","52","","","Percent of Total Billed Charges","neg_dollar:$25.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","49.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","49.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","42.18","86","","","Percent of Total Billed Charges","neg_dollar:$42.18","34.33","70","","","Percent of Total Billed Charges","neg_dollar:$34.33","25.50","52","","","Percent of Total Billed Charges","neg_dollar:$25.50;105% Medicare Outpatient Cost to Charge Ratio of 52%","28.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.81;102% of Medicaid interim rate","36.78","75","","","Percent of Total Billed Charges","neg_dollar:$36.78","42.18","86","","","Percent of Total Billed Charges","neg_dollar:$42.18","34.33","70","","","Percent of Total Billed Charges","neg_dollar:$34.33","27.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.95;103.5% of Medicaid interim rate","49.05","150","","","Percent of Total Billed Charges","neg_dollar:$75.83;150% of Medicaid interim rate","39.24","80","","","Percent of Total Billed Charges","neg_dollar:$39.24;Percent of Total Billed Charges","45.12","92","","","Percent of Total Billed Charges","neg_dollar:$45.12","25.50","52","","","Percent of Total Billed Charges","neg_dollar:$25.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","25.50","52","","","Percent of Total Billed Charges","neg_dollar:$25.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","49.00",""
"CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN","J0744","HCPCS","00409-3300-01","NDC","250","RC","","Facility","Outpatient","50","ML","47.35","47.35","","","","35.00","Fee Schedule","","","","","47.35","Fee Schedule","","","","","4.00","Fee Schedule","","","52","","47.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","24.62","52","","","Percent of Total Billed Charges","neg_dollar:$24.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.62","52","","","Percent of Total Billed Charges","neg_dollar:$24.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","40.72","86","","","Percent of Total Billed Charges","neg_dollar:$40.72","33.14","70","","","Percent of Total Billed Charges","neg_dollar:$33.14","","52","","47.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","27.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.81;102% of Medicaid interim rate","35.51","75","","","Percent of Total Billed Charges","neg_dollar:$35.51","40.72","86","","","Percent of Total Billed Charges","neg_dollar:$40.72","33.14","70","","","Percent of Total Billed Charges","neg_dollar:$33.14","26.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.98;103.5% of Medicaid interim rate","47.35","150","","","Percent of Total Billed Charges","neg_dollar:$73.20;150% of Medicaid interim rate","37.88","80","","","Percent of Total Billed Charges","neg_dollar:$37.88;Percent of Total Billed Charges","43.56","92","","","Percent of Total Billed Charges","neg_dollar:$43.56","24.62","52","","","Percent of Total Billed Charges","neg_dollar:$24.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","47.35","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","47.00",""
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","J0780","HCPCS","00641-6135-01","NDC","250","RC","","Facility","Outpatient","1","UN","101.24","101.24","","","","3.00","Fee Schedule","","","","","54.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","101.24","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","52.64","52","","","Percent of Total Billed Charges","neg_dollar:$52.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.64","52","","","Percent of Total Billed Charges","neg_dollar:$52.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","87.07","86","","","Percent of Total Billed Charges","neg_dollar:$87.07","70.87","70","","","Percent of Total Billed Charges","neg_dollar:$70.87","","52","","84.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","59.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.48;102% of Medicaid interim rate","75.93","75","","","Percent of Total Billed Charges","neg_dollar:$75.93","87.07","86","","","Percent of Total Billed Charges","neg_dollar:$87.07","70.87","70","","","Percent of Total Billed Charges","neg_dollar:$70.87","57.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.70;103.5% of Medicaid interim rate","101.24","150","","","Percent of Total Billed Charges","neg_dollar:$156.52;150% of Medicaid interim rate","80.99","80","","","Percent of Total Billed Charges","neg_dollar:$80.99;Percent of Total Billed Charges","93.14","92","","","Percent of Total Billed Charges","neg_dollar:$93.14","52.64","52","","","Percent of Total Billed Charges","neg_dollar:$52.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","64.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","101.00",""
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","J0780","HCPCS","00641-6135-25","NDC","250","RC","","Facility","Outpatient","1","UN","102.05","102.05","","","","3.00","Fee Schedule","","","","","54.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","102.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","53.06","52","","","Percent of Total Billed Charges","neg_dollar:$53.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","53.06","52","","","Percent of Total Billed Charges","neg_dollar:$53.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","87.76","86","","","Percent of Total Billed Charges","neg_dollar:$87.76","71.43","70","","","Percent of Total Billed Charges","neg_dollar:$71.43","","52","","84.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","59.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.95;102% of Medicaid interim rate","76.53","75","","","Percent of Total Billed Charges","neg_dollar:$76.53","87.76","86","","","Percent of Total Billed Charges","neg_dollar:$87.76","71.43","70","","","Percent of Total Billed Charges","neg_dollar:$71.43","58.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$58.16;103.5% of Medicaid interim rate","102.05","150","","","Percent of Total Billed Charges","neg_dollar:$157.77;150% of Medicaid interim rate","81.64","80","","","Percent of Total Billed Charges","neg_dollar:$81.64;Percent of Total Billed Charges","93.88","92","","","Percent of Total Billed Charges","neg_dollar:$93.88","53.06","52","","","Percent of Total Billed Charges","neg_dollar:$53.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","64.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","102.00",""
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","J0780","HCPCS","00641-6135-01","NDC","636","RC","","Facility","Outpatient","1","UN","100.98","100.98","","","","3.00","Fee Schedule","","","","","54.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","52.51","52","","","Percent of Total Billed Charges","neg_dollar:$52.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","100.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","100.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","86.84","86","","","Percent of Total Billed Charges","neg_dollar:$86.84","70.69","70","","","Percent of Total Billed Charges","neg_dollar:$70.69","52.51","52","","","Percent of Total Billed Charges","neg_dollar:$52.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","59.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.32;102% of Medicaid interim rate","75.73","75","","","Percent of Total Billed Charges","neg_dollar:$75.73","86.84","86","","","Percent of Total Billed Charges","neg_dollar:$86.84","70.69","70","","","Percent of Total Billed Charges","neg_dollar:$70.69","57.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.56;103.5% of Medicaid interim rate","100.98","150","","","Percent of Total Billed Charges","neg_dollar:$156.13;150% of Medicaid interim rate","80.78","80","","","Percent of Total Billed Charges","neg_dollar:$80.78;Percent of Total Billed Charges","92.90","92","","","Percent of Total Billed Charges","neg_dollar:$92.90","52.51","52","","","Percent of Total Billed Charges","neg_dollar:$52.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","52.51","52","","","Percent of Total Billed Charges","neg_dollar:$52.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","100.00",""
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","J0780","HCPCS","00641-6135-25","NDC","636","RC","","Facility","Outpatient","1","UN","98.42","98.42","","","","3.00","Fee Schedule","","","","","54.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","51.18","52","","","Percent of Total Billed Charges","neg_dollar:$51.18;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","98.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","98.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","84.64","86","","","Percent of Total Billed Charges","neg_dollar:$84.64","68.89","70","","","Percent of Total Billed Charges","neg_dollar:$68.89","51.18","52","","","Percent of Total Billed Charges","neg_dollar:$51.18;105% Medicare Outpatient Cost to Charge Ratio of 52%","57.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.82;102% of Medicaid interim rate","73.81","75","","","Percent of Total Billed Charges","neg_dollar:$73.81","84.64","86","","","Percent of Total Billed Charges","neg_dollar:$84.64","68.89","70","","","Percent of Total Billed Charges","neg_dollar:$68.89","56.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.10;103.5% of Medicaid interim rate","98.42","150","","","Percent of Total Billed Charges","neg_dollar:$152.16;150% of Medicaid interim rate","78.74","80","","","Percent of Total Billed Charges","neg_dollar:$78.74;Percent of Total Billed Charges","90.55","92","","","Percent of Total Billed Charges","neg_dollar:$90.55","51.18","52","","","Percent of Total Billed Charges","neg_dollar:$51.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","51.18","52","","","Percent of Total Billed Charges","neg_dollar:$51.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","98.00",""
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","J0780","HCPCS","43066-090-01","NDC","250","RC","","Facility","Outpatient","1","UN","98.10","98.10","","","","3.00","Fee Schedule","","","","","54.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","98.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","51.01","52","","","Percent of Total Billed Charges","neg_dollar:$51.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.01","52","","","Percent of Total Billed Charges","neg_dollar:$51.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","84.36","86","","","Percent of Total Billed Charges","neg_dollar:$84.36","68.66","70","","","Percent of Total Billed Charges","neg_dollar:$68.66","","52","","84.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","57.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.63;102% of Medicaid interim rate","73.57","75","","","Percent of Total Billed Charges","neg_dollar:$73.57","84.36","86","","","Percent of Total Billed Charges","neg_dollar:$84.36","68.66","70","","","Percent of Total Billed Charges","neg_dollar:$68.66","55.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.91;103.5% of Medicaid interim rate","98.10","150","","","Percent of Total Billed Charges","neg_dollar:$151.66;150% of Medicaid interim rate","78.48","80","","","Percent of Total Billed Charges","neg_dollar:$78.48;Percent of Total Billed Charges","90.25","92","","","Percent of Total Billed Charges","neg_dollar:$90.25","51.01","52","","","Percent of Total Billed Charges","neg_dollar:$51.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","64.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","98.00",""
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN","J0780","HCPCS","43066-090-01","NDC","636","RC","","Facility","Outpatient","10","ME","97.04","97.04","","","","3.00","Fee Schedule","","","","","54.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","50.46","52","","","Percent of Total Billed Charges","neg_dollar:$50.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","97.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","97.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","83.45","86","","","Percent of Total Billed Charges","neg_dollar:$83.45","67.92","70","","","Percent of Total Billed Charges","neg_dollar:$67.92","50.46","52","","","Percent of Total Billed Charges","neg_dollar:$50.46;105% Medicare Outpatient Cost to Charge Ratio of 52%","57.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.01;102% of Medicaid interim rate","72.78","75","","","Percent of Total Billed Charges","neg_dollar:$72.78","83.45","86","","","Percent of Total Billed Charges","neg_dollar:$83.45","67.92","70","","","Percent of Total Billed Charges","neg_dollar:$67.92","55.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.31;103.5% of Medicaid interim rate","97.04","150","","","Percent of Total Billed Charges","neg_dollar:$150.02;150% of Medicaid interim rate","77.63","80","","","Percent of Total Billed Charges","neg_dollar:$77.63;Percent of Total Billed Charges","89.27","92","","","Percent of Total Billed Charges","neg_dollar:$89.27","50.46","52","","","Percent of Total Billed Charges","neg_dollar:$50.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","50.46","52","","","Percent of Total Billed Charges","neg_dollar:$50.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","97.00",""
"DAPTOMYCIN 350 MG IV SOLR","J0873","HCPCS","70594-053-01","NDC","636","RC","","Facility","Outpatient","10","UN","0.40","0.40","","","","0.40","Fee Schedule","","","","","0.40","Fee Schedule","101% of Medicare Fee Schedule","","","","0.40","Fee Schedule","","0.20","52","","","Percent of Total Billed Charges","neg_dollar:$0.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.34","86","","","Percent of Total Billed Charges","neg_dollar:$0.34","0.28","70","","","Percent of Total Billed Charges","neg_dollar:$0.28","0.20","52","","","Percent of Total Billed Charges","neg_dollar:$0.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.23;102% of Medicaid interim rate","0.30","75","","","Percent of Total Billed Charges","neg_dollar:$0.30","0.34","86","","","Percent of Total Billed Charges","neg_dollar:$0.34","0.28","70","","","Percent of Total Billed Charges","neg_dollar:$0.28","0.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.22;103.5% of Medicaid interim rate","0.40","150","","","Percent of Total Billed Charges","neg_dollar:$0.62;150% of Medicaid interim rate","0.32","80","","","Percent of Total Billed Charges","neg_dollar:$0.32;Percent of Total Billed Charges","0.37","92","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.20","52","","","Percent of Total Billed Charges","neg_dollar:$0.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.20","52","","","Percent of Total Billed Charges","neg_dollar:$0.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DAPTOMYCIN 500 MG IV SOLR","J0878","HCPCS","43598-413-11","NDC","636","RC","","Facility","Outpatient","1","UN","0.56","0.56","","","","0.56","Fee Schedule","","","","","0.56","Fee Schedule","101% of Medicare Fee Schedule","","","","0.56","Fee Schedule","","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","86","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","70","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% of Medicaid interim rate","0.42","75","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.48","86","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","70","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;103.5% of Medicaid interim rate","0.56","150","","","Percent of Total Billed Charges","neg_dollar:$0.88;150% of Medicaid interim rate","0.45","80","","","Percent of Total Billed Charges","neg_dollar:$0.45;Percent of Total Billed Charges","0.52","92","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DAPTOMYCIN 500 MG IV SOLR","J0878","HCPCS","67457-941-15","NDC","636","RC","","Facility","Outpatient","1","UN","0.30","0.30","","","","0.30","Fee Schedule","","","","","0.30","Fee Schedule","101% of Medicare Fee Schedule","","","","0.30","Fee Schedule","","0.15","52","","","Percent of Total Billed Charges","neg_dollar:$0.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","86","","","Percent of Total Billed Charges","neg_dollar:$0.26","0.21","70","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.15","52","","","Percent of Total Billed Charges","neg_dollar:$0.15;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.18;102% of Medicaid interim rate","0.23","75","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.26","86","","","Percent of Total Billed Charges","neg_dollar:$0.26","0.21","70","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.17;103.5% of Medicaid interim rate","0.30","150","","","Percent of Total Billed Charges","neg_dollar:$0.47;150% of Medicaid interim rate","0.24","80","","","Percent of Total Billed Charges","neg_dollar:$0.24;Percent of Total Billed Charges","0.28","92","","","Percent of Total Billed Charges","neg_dollar:$0.28","0.15","52","","","Percent of Total Billed Charges","neg_dollar:$0.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.15","52","","","Percent of Total Billed Charges","neg_dollar:$0.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DAPTOMYCIN 500 MG IV SOLR","J0878","HCPCS","43598-413-11","NDC","636","RC","","Facility","Outpatient","1","UN","0.20","0.20","","","","0.20","Fee Schedule","","","","","0.20","Fee Schedule","101% of Medicare Fee Schedule","","","","0.20","Fee Schedule","","0.10","52","","","Percent of Total Billed Charges","neg_dollar:$0.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.17","86","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.13","70","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.10","52","","","Percent of Total Billed Charges","neg_dollar:$0.10;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.11;102% of Medicaid interim rate","0.15","75","","","Percent of Total Billed Charges","neg_dollar:$0.15","0.17","86","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.13","70","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.11;103.5% of Medicaid interim rate","0.20","150","","","Percent of Total Billed Charges","neg_dollar:$0.30;150% of Medicaid interim rate","0.16","80","","","Percent of Total Billed Charges","neg_dollar:$0.16;Percent of Total Billed Charges","0.18","92","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.10","52","","","Percent of Total Billed Charges","neg_dollar:$0.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.10","52","","","Percent of Total Billed Charges","neg_dollar:$0.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DAPTOMYCIN 500 MG IV SOLR","J0878","HCPCS","43598-413-11","NDC","250","RC","","Facility","Outpatient","1","UN","0.54","0.54","","","","0.54","Fee Schedule","","","","","0.54","Fee Schedule","","","","","0.54","Fee Schedule","","","52","","0.54","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","","52","","0.54","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% of Medicaid interim rate","0.41","75","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.31;103.5% of Medicaid interim rate","0.54","150","","","Percent of Total Billed Charges","neg_dollar:$0.84;150% of Medicaid interim rate","0.43","80","","","Percent of Total Billed Charges","neg_dollar:$0.43;Percent of Total Billed Charges","0.50","92","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.54","Fee Schedule","","1.00","1.00",""
"DAPTOMYCIN 500 MG IV SOLR","J0878","HCPCS","43598-413-11","NDC","636","RC","","Facility","Outpatient","1","UN","0.48","0.48","","","","0.48","Fee Schedule","","","","","0.48","Fee Schedule","101% of Medicare Fee Schedule","","","","0.48","Fee Schedule","","0.25","52","","","Percent of Total Billed Charges","neg_dollar:$0.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","86","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.34","70","","","Percent of Total Billed Charges","neg_dollar:$0.34","0.25","52","","","Percent of Total Billed Charges","neg_dollar:$0.25;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% of Medicaid interim rate","0.36","75","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.41","86","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.34","70","","","Percent of Total Billed Charges","neg_dollar:$0.34","0.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.27;103.5% of Medicaid interim rate","0.48","150","","","Percent of Total Billed Charges","neg_dollar:$0.75;150% of Medicaid interim rate","0.39","80","","","Percent of Total Billed Charges","neg_dollar:$0.39;Percent of Total Billed Charges","0.44","92","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.25","52","","","Percent of Total Billed Charges","neg_dollar:$0.25;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.25","52","","","Percent of Total Billed Charges","neg_dollar:$0.25;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DARBEPOETIN ALFA 100 MCG/ML IJ SOLN","J0881","HCPCS","55513-005-04","NDC","636","RC","","Facility","Outpatient","1","ML","16.35","16.35","","","","16.35","Fee Schedule","","","","","16.35","Fee Schedule","101% of Medicare Fee Schedule","","","","16.35","Fee Schedule","","8.50","52","","","Percent of Total Billed Charges","neg_dollar:$8.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.06","86","","","Percent of Total Billed Charges","neg_dollar:$14.06","11.44","70","","","Percent of Total Billed Charges","neg_dollar:$11.44","8.50","52","","","Percent of Total Billed Charges","neg_dollar:$8.50;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.60;102% of Medicaid interim rate","12.26","75","","","Percent of Total Billed Charges","neg_dollar:$12.26","14.06","86","","","Percent of Total Billed Charges","neg_dollar:$14.06","11.44","70","","","Percent of Total Billed Charges","neg_dollar:$11.44","9.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.32;103.5% of Medicaid interim rate","16.35","150","","","Percent of Total Billed Charges","neg_dollar:$25.28;150% of Medicaid interim rate","13.08","80","","","Percent of Total Billed Charges","neg_dollar:$13.08;Percent of Total Billed Charges","15.04","92","","","Percent of Total Billed Charges","neg_dollar:$15.04","8.50","52","","","Percent of Total Billed Charges","neg_dollar:$8.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.50","52","","","Percent of Total Billed Charges","neg_dollar:$8.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","16.00",""
"DARBEPOETIN ALFA 100 MCG/ML IJ SOLN","J0881","HCPCS","55513-005-01","NDC","636","RC","","Facility","Outpatient","1","ML","16.35","16.35","","","","16.35","Fee Schedule","","","","","16.35","Fee Schedule","101% of Medicare Fee Schedule","","","","16.35","Fee Schedule","","8.50","52","","","Percent of Total Billed Charges","neg_dollar:$8.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.06","86","","","Percent of Total Billed Charges","neg_dollar:$14.06","11.44","70","","","Percent of Total Billed Charges","neg_dollar:$11.44","8.50","52","","","Percent of Total Billed Charges","neg_dollar:$8.50;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.60;102% of Medicaid interim rate","12.26","75","","","Percent of Total Billed Charges","neg_dollar:$12.26","14.06","86","","","Percent of Total Billed Charges","neg_dollar:$14.06","11.44","70","","","Percent of Total Billed Charges","neg_dollar:$11.44","9.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.32;103.5% of Medicaid interim rate","16.35","150","","","Percent of Total Billed Charges","neg_dollar:$25.28;150% of Medicaid interim rate","13.08","80","","","Percent of Total Billed Charges","neg_dollar:$13.08;Percent of Total Billed Charges","15.04","92","","","Percent of Total Billed Charges","neg_dollar:$15.04","8.50","52","","","Percent of Total Billed Charges","neg_dollar:$8.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.50","52","","","Percent of Total Billed Charges","neg_dollar:$8.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","16.00",""
"DARBEPOETIN ALFA 100 MCG/ML IJ SOLN","J0881","HCPCS","55513-005-01","NDC","636","RC","","Facility","Outpatient","1","ML","7.74","7.74","","","","7.74","Fee Schedule","","","","","7.74","Fee Schedule","101% of Medicare Fee Schedule","","","","7.74","Fee Schedule","","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","7.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","7.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.65","86","","","Percent of Total Billed Charges","neg_dollar:$6.65","5.41","70","","","Percent of Total Billed Charges","neg_dollar:$5.41","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;105% Medicare Outpatient Cost to Charge Ratio of 52%","4.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.54;102% of Medicaid interim rate","5.80","75","","","Percent of Total Billed Charges","neg_dollar:$5.80","6.65","86","","","Percent of Total Billed Charges","neg_dollar:$6.65","5.41","70","","","Percent of Total Billed Charges","neg_dollar:$5.41","4.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.41;103.5% of Medicaid interim rate","7.74","150","","","Percent of Total Billed Charges","neg_dollar:$11.96;150% of Medicaid interim rate","6.19","80","","","Percent of Total Billed Charges","neg_dollar:$6.19;Percent of Total Billed Charges","7.12","92","","","Percent of Total Billed Charges","neg_dollar:$7.12","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","7.00",""
"DARBEPOETIN ALFA 100 MCG/ML IJ SOLN","J0881","HCPCS","55513-005-01","NDC","636","RC","","Facility","Outpatient","1","ML","16.57","16.57","","","","16.57","Fee Schedule","","","","","16.57","Fee Schedule","101% of Medicare Fee Schedule","","","","16.57","Fee Schedule","","8.61","52","","","Percent of Total Billed Charges","neg_dollar:$8.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.25","86","","","Percent of Total Billed Charges","neg_dollar:$14.25","11.60","70","","","Percent of Total Billed Charges","neg_dollar:$11.60","8.61","52","","","Percent of Total Billed Charges","neg_dollar:$8.61;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.73;102% of Medicaid interim rate","12.43","75","","","Percent of Total Billed Charges","neg_dollar:$12.43","14.25","86","","","Percent of Total Billed Charges","neg_dollar:$14.25","11.60","70","","","Percent of Total Billed Charges","neg_dollar:$11.60","9.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.44;103.5% of Medicaid interim rate","16.57","150","","","Percent of Total Billed Charges","neg_dollar:$25.62;150% of Medicaid interim rate","13.25","80","","","Percent of Total Billed Charges","neg_dollar:$13.25;Percent of Total Billed Charges","15.24","92","","","Percent of Total Billed Charges","neg_dollar:$15.24","8.61","52","","","Percent of Total Billed Charges","neg_dollar:$8.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.61","52","","","Percent of Total Billed Charges","neg_dollar:$8.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","16.00",""
"DARBEPOETIN ALFA 25 MCG/0.42ML IJ SOSY","J0881","HCPCS","55513-057-01","NDC","636","RC","","Facility","Outpatient","1","EA","17.23","17.23","","","","17.23","Fee Schedule","","","","","17.23","Fee Schedule","101% of Medicare Fee Schedule","","","","17.23","Fee Schedule","","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.23","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.23","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.81","86","","","Percent of Total Billed Charges","neg_dollar:$14.81","12.06","70","","","Percent of Total Billed Charges","neg_dollar:$12.06","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.12;102% of Medicaid interim rate","12.92","75","","","Percent of Total Billed Charges","neg_dollar:$12.92","14.81","86","","","Percent of Total Billed Charges","neg_dollar:$14.81","12.06","70","","","Percent of Total Billed Charges","neg_dollar:$12.06","9.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.82;103.5% of Medicaid interim rate","17.23","150","","","Percent of Total Billed Charges","neg_dollar:$26.63;150% of Medicaid interim rate","13.78","80","","","Percent of Total Billed Charges","neg_dollar:$13.78;Percent of Total Billed Charges","15.85","92","","","Percent of Total Billed Charges","neg_dollar:$15.85","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","17.00",""
"DARBEPOETIN ALFA 25 MCG/0.42ML IJ SOSY","J0881","HCPCS","55513-057-04","NDC","636","RC","","Facility","Outpatient","1","EA","18.98","18.98","","","","18.98","Fee Schedule","","","","","18.98","Fee Schedule","101% of Medicare Fee Schedule","","","","18.98","Fee Schedule","","9.86","52","","","Percent of Total Billed Charges","neg_dollar:$9.86;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","18.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","18.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.32","86","","","Percent of Total Billed Charges","neg_dollar:$16.32","13.28","70","","","Percent of Total Billed Charges","neg_dollar:$13.28","9.86","52","","","Percent of Total Billed Charges","neg_dollar:$9.86;105% Medicare Outpatient Cost to Charge Ratio of 52%","11.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.15;102% of Medicaid interim rate","14.23","75","","","Percent of Total Billed Charges","neg_dollar:$14.23","16.32","86","","","Percent of Total Billed Charges","neg_dollar:$16.32","13.28","70","","","Percent of Total Billed Charges","neg_dollar:$13.28","10.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.81;103.5% of Medicaid interim rate","18.98","150","","","Percent of Total Billed Charges","neg_dollar:$29.34;150% of Medicaid interim rate","15.18","80","","","Percent of Total Billed Charges","neg_dollar:$15.18;Percent of Total Billed Charges","17.46","92","","","Percent of Total Billed Charges","neg_dollar:$17.46","9.86","52","","","Percent of Total Billed Charges","neg_dollar:$9.86;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.86","52","","","Percent of Total Billed Charges","neg_dollar:$9.86;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","18.00",""
"DARBEPOETIN ALFA 25 MCG/0.42ML IJ SOSY","J0881","HCPCS","55513-057-04","NDC","636","RC","","Facility","Outpatient","1","EA","17.23","17.23","","","","17.23","Fee Schedule","","","","","17.23","Fee Schedule","101% of Medicare Fee Schedule","","","","17.23","Fee Schedule","","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.23","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.23","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.81","86","","","Percent of Total Billed Charges","neg_dollar:$14.81","12.06","70","","","Percent of Total Billed Charges","neg_dollar:$12.06","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.12;102% of Medicaid interim rate","12.92","75","","","Percent of Total Billed Charges","neg_dollar:$12.92","14.81","86","","","Percent of Total Billed Charges","neg_dollar:$14.81","12.06","70","","","Percent of Total Billed Charges","neg_dollar:$12.06","9.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.82;103.5% of Medicaid interim rate","17.23","150","","","Percent of Total Billed Charges","neg_dollar:$26.63;150% of Medicaid interim rate","13.78","80","","","Percent of Total Billed Charges","neg_dollar:$13.78;Percent of Total Billed Charges","15.85","92","","","Percent of Total Billed Charges","neg_dollar:$15.85","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","17.00",""
"DARBEPOETIN ALFA 40 MCG/0.4ML IJ SOSY","J0881","HCPCS","55513-021-01","NDC","636","RC","","Facility","Outpatient","1","EA","17.66","17.66","","","","17.66","Fee Schedule","","","","","17.66","Fee Schedule","101% of Medicare Fee Schedule","","","","17.66","Fee Schedule","","9.18","52","","","Percent of Total Billed Charges","neg_dollar:$9.18;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.19","86","","","Percent of Total Billed Charges","neg_dollar:$15.19","12.36","70","","","Percent of Total Billed Charges","neg_dollar:$12.36","9.18","52","","","Percent of Total Billed Charges","neg_dollar:$9.18;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.37;102% of Medicaid interim rate","13.25","75","","","Percent of Total Billed Charges","neg_dollar:$13.25","15.19","86","","","Percent of Total Billed Charges","neg_dollar:$15.19","12.36","70","","","Percent of Total Billed Charges","neg_dollar:$12.36","10.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.07;103.5% of Medicaid interim rate","17.66","150","","","Percent of Total Billed Charges","neg_dollar:$27.31;150% of Medicaid interim rate","14.13","80","","","Percent of Total Billed Charges","neg_dollar:$14.13;Percent of Total Billed Charges","16.25","92","","","Percent of Total Billed Charges","neg_dollar:$16.25","9.18","52","","","Percent of Total Billed Charges","neg_dollar:$9.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.18","52","","","Percent of Total Billed Charges","neg_dollar:$9.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","17.00",""
"DARBEPOETIN ALFA 40 MCG/0.4ML IJ SOSY","J0881","HCPCS","55513-021-04","NDC","636","RC","","Facility","Outpatient","1","EA","17.66","17.66","","","","17.66","Fee Schedule","","","","","17.66","Fee Schedule","101% of Medicare Fee Schedule","","","","17.66","Fee Schedule","","9.18","52","","","Percent of Total Billed Charges","neg_dollar:$9.18;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.19","86","","","Percent of Total Billed Charges","neg_dollar:$15.19","12.36","70","","","Percent of Total Billed Charges","neg_dollar:$12.36","9.18","52","","","Percent of Total Billed Charges","neg_dollar:$9.18;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.37;102% of Medicaid interim rate","13.25","75","","","Percent of Total Billed Charges","neg_dollar:$13.25","15.19","86","","","Percent of Total Billed Charges","neg_dollar:$15.19","12.36","70","","","Percent of Total Billed Charges","neg_dollar:$12.36","10.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.07;103.5% of Medicaid interim rate","17.66","150","","","Percent of Total Billed Charges","neg_dollar:$27.31;150% of Medicaid interim rate","14.13","80","","","Percent of Total Billed Charges","neg_dollar:$14.13;Percent of Total Billed Charges","16.25","92","","","Percent of Total Billed Charges","neg_dollar:$16.25","9.18","52","","","Percent of Total Billed Charges","neg_dollar:$9.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.18","52","","","Percent of Total Billed Charges","neg_dollar:$9.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","17.00",""
"DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY","J0881","HCPCS","55513-023-01","NDC","636","RC","","Facility","Outpatient","1","EA","17.35","17.35","","","","17.35","Fee Schedule","","","","","17.35","Fee Schedule","101% of Medicare Fee Schedule","","","","17.35","Fee Schedule","","9.02","52","","","Percent of Total Billed Charges","neg_dollar:$9.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.92","86","","","Percent of Total Billed Charges","neg_dollar:$14.92","12.14","70","","","Percent of Total Billed Charges","neg_dollar:$12.14","9.02","52","","","Percent of Total Billed Charges","neg_dollar:$9.02;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.19;102% of Medicaid interim rate","13.01","75","","","Percent of Total Billed Charges","neg_dollar:$13.01","14.92","86","","","Percent of Total Billed Charges","neg_dollar:$14.92","12.14","70","","","Percent of Total Billed Charges","neg_dollar:$12.14","9.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.89;103.5% of Medicaid interim rate","17.35","150","","","Percent of Total Billed Charges","neg_dollar:$26.83;150% of Medicaid interim rate","13.88","80","","","Percent of Total Billed Charges","neg_dollar:$13.88;Percent of Total Billed Charges","15.96","92","","","Percent of Total Billed Charges","neg_dollar:$15.96","9.02","52","","","Percent of Total Billed Charges","neg_dollar:$9.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.02","52","","","Percent of Total Billed Charges","neg_dollar:$9.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","17.00",""
"DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY","J0881","HCPCS","55513-023-01","NDC","636","RC","","Facility","Outpatient","1","EA","7.74","7.74","","","","7.74","Fee Schedule","","","","","7.74","Fee Schedule","101% of Medicare Fee Schedule","","","","7.74","Fee Schedule","","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","7.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","7.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.65","86","","","Percent of Total Billed Charges","neg_dollar:$6.65","5.41","70","","","Percent of Total Billed Charges","neg_dollar:$5.41","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;105% Medicare Outpatient Cost to Charge Ratio of 52%","4.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.54;102% of Medicaid interim rate","5.80","75","","","Percent of Total Billed Charges","neg_dollar:$5.80","6.65","86","","","Percent of Total Billed Charges","neg_dollar:$6.65","5.41","70","","","Percent of Total Billed Charges","neg_dollar:$5.41","4.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.41;103.5% of Medicaid interim rate","7.74","150","","","Percent of Total Billed Charges","neg_dollar:$11.96;150% of Medicaid interim rate","6.19","80","","","Percent of Total Billed Charges","neg_dollar:$6.19;Percent of Total Billed Charges","7.12","92","","","Percent of Total Billed Charges","neg_dollar:$7.12","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","7.00",""
"DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY","J0881","HCPCS","55513-023-04","NDC","636","RC","","Facility","Outpatient","1","EA","7.74","7.74","","","","7.74","Fee Schedule","","","","","7.74","Fee Schedule","101% of Medicare Fee Schedule","","","","7.74","Fee Schedule","","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","7.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","7.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.65","86","","","Percent of Total Billed Charges","neg_dollar:$6.65","5.41","70","","","Percent of Total Billed Charges","neg_dollar:$5.41","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;105% Medicare Outpatient Cost to Charge Ratio of 52%","4.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.54;102% of Medicaid interim rate","5.80","75","","","Percent of Total Billed Charges","neg_dollar:$5.80","6.65","86","","","Percent of Total Billed Charges","neg_dollar:$6.65","5.41","70","","","Percent of Total Billed Charges","neg_dollar:$5.41","4.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.41;103.5% of Medicaid interim rate","7.74","150","","","Percent of Total Billed Charges","neg_dollar:$11.96;150% of Medicaid interim rate","6.19","80","","","Percent of Total Billed Charges","neg_dollar:$6.19;Percent of Total Billed Charges","7.12","92","","","Percent of Total Billed Charges","neg_dollar:$7.12","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.02","52","","","Percent of Total Billed Charges","neg_dollar:$4.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","7.00",""
"DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY","J0881","HCPCS","55513-023-04","NDC","636","RC","","Facility","Outpatient","1","EA","17.23","17.23","","","","17.23","Fee Schedule","","","","","17.23","Fee Schedule","101% of Medicare Fee Schedule","","","","17.23","Fee Schedule","","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.23","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.23","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.81","86","","","Percent of Total Billed Charges","neg_dollar:$14.81","12.06","70","","","Percent of Total Billed Charges","neg_dollar:$12.06","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.12;102% of Medicaid interim rate","12.92","75","","","Percent of Total Billed Charges","neg_dollar:$12.92","14.81","86","","","Percent of Total Billed Charges","neg_dollar:$14.81","12.06","70","","","Percent of Total Billed Charges","neg_dollar:$12.06","9.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.82;103.5% of Medicaid interim rate","17.23","150","","","Percent of Total Billed Charges","neg_dollar:$26.63;150% of Medicaid interim rate","13.78","80","","","Percent of Total Billed Charges","neg_dollar:$13.78;Percent of Total Billed Charges","15.85","92","","","Percent of Total Billed Charges","neg_dollar:$15.85","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.95","52","","","Percent of Total Billed Charges","neg_dollar:$8.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","17.00",""
"DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY","J0881","HCPCS","55513-023-01","NDC","636","RC","","Facility","Outpatient","1","EA","16.93","16.93","","","","16.93","Fee Schedule","","","","","16.93","Fee Schedule","101% of Medicare Fee Schedule","","","","16.93","Fee Schedule","","8.80","52","","","Percent of Total Billed Charges","neg_dollar:$8.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.56","86","","","Percent of Total Billed Charges","neg_dollar:$14.56","11.85","70","","","Percent of Total Billed Charges","neg_dollar:$11.85","8.80","52","","","Percent of Total Billed Charges","neg_dollar:$8.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.95;102% of Medicaid interim rate","12.70","75","","","Percent of Total Billed Charges","neg_dollar:$12.70","14.56","86","","","Percent of Total Billed Charges","neg_dollar:$14.56","11.85","70","","","Percent of Total Billed Charges","neg_dollar:$11.85","9.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.65;103.5% of Medicaid interim rate","16.93","150","","","Percent of Total Billed Charges","neg_dollar:$26.18;150% of Medicaid interim rate","13.55","80","","","Percent of Total Billed Charges","neg_dollar:$13.55;Percent of Total Billed Charges","15.58","92","","","Percent of Total Billed Charges","neg_dollar:$15.58","8.80","52","","","Percent of Total Billed Charges","neg_dollar:$8.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.80","52","","","Percent of Total Billed Charges","neg_dollar:$8.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","16.00",""
"EPOETIN ALFA 10000 UNIT/ML IJ SOLN","J0885","HCPCS","55513-144-10","NDC","636","RC","","Facility","Outpatient","1","ML","41.91","41.91","","","","41.91","Fee Schedule","","","","","41.91","Fee Schedule","101% of Medicare Fee Schedule","","","","41.91","Fee Schedule","","21.79","52","","","Percent of Total Billed Charges","neg_dollar:$21.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","41.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","41.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","36.04","86","","","Percent of Total Billed Charges","neg_dollar:$36.04","29.33","70","","","Percent of Total Billed Charges","neg_dollar:$29.33","21.79","52","","","Percent of Total Billed Charges","neg_dollar:$21.79;105% Medicare Outpatient Cost to Charge Ratio of 52%","24.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.62;102% of Medicaid interim rate","31.43","75","","","Percent of Total Billed Charges","neg_dollar:$31.43","36.04","86","","","Percent of Total Billed Charges","neg_dollar:$36.04","29.33","70","","","Percent of Total Billed Charges","neg_dollar:$29.33","23.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$23.88;103.5% of Medicaid interim rate","41.91","150","","","Percent of Total Billed Charges","neg_dollar:$64.79;150% of Medicaid interim rate","33.52","80","","","Percent of Total Billed Charges","neg_dollar:$33.52;Percent of Total Billed Charges","38.55","92","","","Percent of Total Billed Charges","neg_dollar:$38.55","21.79","52","","","Percent of Total Billed Charges","neg_dollar:$21.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","21.79","52","","","Percent of Total Billed Charges","neg_dollar:$21.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","21.00","41.00",""
"EPOETIN ALFA 10000 UNIT/ML IJ SOLN","J0885","HCPCS","55513-144-01","NDC","636","RC","","Facility","Outpatient","1","ML","38.61","38.61","","","","38.61","Fee Schedule","","","","","38.61","Fee Schedule","101% of Medicare Fee Schedule","","","","38.61","Fee Schedule","","20.07","52","","","Percent of Total Billed Charges","neg_dollar:$20.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","38.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","38.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","33.20","86","","","Percent of Total Billed Charges","neg_dollar:$33.20","27.03","70","","","Percent of Total Billed Charges","neg_dollar:$27.03","20.07","52","","","Percent of Total Billed Charges","neg_dollar:$20.07;105% Medicare Outpatient Cost to Charge Ratio of 52%","22.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.68;102% of Medicaid interim rate","28.96","75","","","Percent of Total Billed Charges","neg_dollar:$28.96","33.20","86","","","Percent of Total Billed Charges","neg_dollar:$33.20","27.03","70","","","Percent of Total Billed Charges","neg_dollar:$27.03","22.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.01;103.5% of Medicaid interim rate","38.61","150","","","Percent of Total Billed Charges","neg_dollar:$59.70;150% of Medicaid interim rate","30.89","80","","","Percent of Total Billed Charges","neg_dollar:$30.89;Percent of Total Billed Charges","35.52","92","","","Percent of Total Billed Charges","neg_dollar:$35.52","20.07","52","","","Percent of Total Billed Charges","neg_dollar:$20.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","20.07","52","","","Percent of Total Billed Charges","neg_dollar:$20.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","20.00","38.00",""
"EPOETIN ALFA 10000 UNIT/ML IJ SOLN","J0885","HCPCS","55513-144-01","NDC","636","RC","","Facility","Outpatient","1","ML","17.76","17.76","","","","17.76","Fee Schedule","","","","","17.76","Fee Schedule","101% of Medicare Fee Schedule","","","","17.76","Fee Schedule","","9.23","52","","","Percent of Total Billed Charges","neg_dollar:$9.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.76","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.76","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.27","86","","","Percent of Total Billed Charges","neg_dollar:$15.27","12.43","70","","","Percent of Total Billed Charges","neg_dollar:$12.43","9.23","52","","","Percent of Total Billed Charges","neg_dollar:$9.23;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.43;102% of Medicaid interim rate","13.32","75","","","Percent of Total Billed Charges","neg_dollar:$13.32","15.27","86","","","Percent of Total Billed Charges","neg_dollar:$15.27","12.43","70","","","Percent of Total Billed Charges","neg_dollar:$12.43","10.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.12;103.5% of Medicaid interim rate","17.76","150","","","Percent of Total Billed Charges","neg_dollar:$27.46;150% of Medicaid interim rate","14.21","80","","","Percent of Total Billed Charges","neg_dollar:$14.21;Percent of Total Billed Charges","16.34","92","","","Percent of Total Billed Charges","neg_dollar:$16.34","9.23","52","","","Percent of Total Billed Charges","neg_dollar:$9.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.23","52","","","Percent of Total Billed Charges","neg_dollar:$9.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","17.00",""
"EPOETIN ALFA 10000 UNIT/ML IJ SOLN","J0885","HCPCS","55513-144-01","NDC","636","RC","","Facility","Outpatient","1","ML","41.91","41.91","","","","41.91","Fee Schedule","","","","","41.91","Fee Schedule","101% of Medicare Fee Schedule","","","","41.91","Fee Schedule","","21.79","52","","","Percent of Total Billed Charges","neg_dollar:$21.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","41.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","41.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","36.04","86","","","Percent of Total Billed Charges","neg_dollar:$36.04","29.33","70","","","Percent of Total Billed Charges","neg_dollar:$29.33","21.79","52","","","Percent of Total Billed Charges","neg_dollar:$21.79;105% Medicare Outpatient Cost to Charge Ratio of 52%","24.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.62;102% of Medicaid interim rate","31.43","75","","","Percent of Total Billed Charges","neg_dollar:$31.43","36.04","86","","","Percent of Total Billed Charges","neg_dollar:$36.04","29.33","70","","","Percent of Total Billed Charges","neg_dollar:$29.33","23.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$23.88;103.5% of Medicaid interim rate","41.91","150","","","Percent of Total Billed Charges","neg_dollar:$64.79;150% of Medicaid interim rate","33.52","80","","","Percent of Total Billed Charges","neg_dollar:$33.52;Percent of Total Billed Charges","38.55","92","","","Percent of Total Billed Charges","neg_dollar:$38.55","21.79","52","","","Percent of Total Billed Charges","neg_dollar:$21.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","21.79","52","","","Percent of Total Billed Charges","neg_dollar:$21.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","21.00","41.00",""
"DENOSUMAB 60 MG/ML SC SOSY","J0897","HCPCS","55513-710-21","NDC","636","RC","","Facility","Outpatient","1","ML","61.61","61.61","","","","61.61","Fee Schedule","","","","","61.61","Fee Schedule","101% of Medicare Fee Schedule","","","","61.61","Fee Schedule","","32.04","52","","","Percent of Total Billed Charges","neg_dollar:$32.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","61.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","61.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","52.98","86","","","Percent of Total Billed Charges","neg_dollar:$52.98","43.13","70","","","Percent of Total Billed Charges","neg_dollar:$43.13","32.04","52","","","Percent of Total Billed Charges","neg_dollar:$32.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","36.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$36.19;102% of Medicaid interim rate","46.21","75","","","Percent of Total Billed Charges","neg_dollar:$46.21","52.98","86","","","Percent of Total Billed Charges","neg_dollar:$52.98","43.13","70","","","Percent of Total Billed Charges","neg_dollar:$43.13","35.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.12;103.5% of Medicaid interim rate","61.61","150","","","Percent of Total Billed Charges","neg_dollar:$95.26;150% of Medicaid interim rate","49.29","80","","","Percent of Total Billed Charges","neg_dollar:$49.29;Percent of Total Billed Charges","56.68","92","","","Percent of Total Billed Charges","neg_dollar:$56.68","32.04","52","","","Percent of Total Billed Charges","neg_dollar:$32.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","32.04","52","","","Percent of Total Billed Charges","neg_dollar:$32.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","32.00","61.00",""
"DENOSUMAB 60 MG/ML SC SOSY","J0897","HCPCS","55513-710-01","NDC","636","RC","","Facility","Outpatient","1","ML","60.99","60.99","","","","60.99","Fee Schedule","","","","","60.99","Fee Schedule","101% of Medicare Fee Schedule","","","","60.99","Fee Schedule","","31.71","52","","","Percent of Total Billed Charges","neg_dollar:$31.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","60.99","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","60.99","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","52.45","86","","","Percent of Total Billed Charges","neg_dollar:$52.45","42.69","70","","","Percent of Total Billed Charges","neg_dollar:$42.69","31.71","52","","","Percent of Total Billed Charges","neg_dollar:$31.71;105% Medicare Outpatient Cost to Charge Ratio of 52%","35.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.83;102% of Medicaid interim rate","45.74","75","","","Percent of Total Billed Charges","neg_dollar:$45.74","52.45","86","","","Percent of Total Billed Charges","neg_dollar:$52.45","42.69","70","","","Percent of Total Billed Charges","neg_dollar:$42.69","34.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.76;103.5% of Medicaid interim rate","60.99","150","","","Percent of Total Billed Charges","neg_dollar:$94.30;150% of Medicaid interim rate","48.79","80","","","Percent of Total Billed Charges","neg_dollar:$48.79;Percent of Total Billed Charges","56.11","92","","","Percent of Total Billed Charges","neg_dollar:$56.11","31.71","52","","","Percent of Total Billed Charges","neg_dollar:$31.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","31.71","52","","","Percent of Total Billed Charges","neg_dollar:$31.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","31.00","60.00",""
"METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP","J1010","HCPCS","70121-1574-5","NDC","636","RC","","Facility","Outpatient","1","ML","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","101% of Medicare Fee Schedule","","","","1.50","Fee Schedule","","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","70","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","70","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.32;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP","J1010","HCPCS","70121-1574-1","NDC","250","RC","","Facility","Outpatient","1","ML","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","70","","","Percent of Total Billed Charges","neg_dollar:$1.05","","52","","1.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","70","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.32;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.50","Fee Schedule","","1.00","1.00",""
"MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSY","J1050","HCPCS","66993-371-79","NDC","250","RC","","Facility","Outpatient","1","ML","1.54","1.54","","","","1.54","Fee Schedule","","","","","1.54","Fee Schedule","","","","","1.54","Fee Schedule","","","52","","1.54","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","86","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.54","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.90;102% of Medicaid interim rate","1.15","75","","","Percent of Total Billed Charges","neg_dollar:$1.15","1.32","86","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.87;103.5% of Medicaid interim rate","1.54","150","","","Percent of Total Billed Charges","neg_dollar:$2.38;150% of Medicaid interim rate","1.23","80","","","Percent of Total Billed Charges","neg_dollar:$1.23;Percent of Total Billed Charges","1.41","92","","","Percent of Total Billed Charges","neg_dollar:$1.41","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.54","Fee Schedule","","1.00","1.00",""
"DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN","J1100","HCPCS","63323-506-01","NDC","636","RC","","Facility","Outpatient","1","ML","8.87","8.87","","","","8.87","Fee Schedule","","","","","8.87","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","4.61","52","","","Percent of Total Billed Charges","neg_dollar:$4.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.63","86","","","Percent of Total Billed Charges","neg_dollar:$7.63","6.21","70","","","Percent of Total Billed Charges","neg_dollar:$6.21","4.61","52","","","Percent of Total Billed Charges","neg_dollar:$4.61;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.21;102% of Medicaid interim rate","6.65","75","","","Percent of Total Billed Charges","neg_dollar:$6.65","7.63","86","","","Percent of Total Billed Charges","neg_dollar:$7.63","6.21","70","","","Percent of Total Billed Charges","neg_dollar:$6.21","5.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.05;103.5% of Medicaid interim rate","8.87","150","","","Percent of Total Billed Charges","neg_dollar:$13.72;150% of Medicaid interim rate","7.10","80","","","Percent of Total Billed Charges","neg_dollar:$7.10;Percent of Total Billed Charges","8.16","92","","","Percent of Total Billed Charges","neg_dollar:$8.16","4.61","52","","","Percent of Total Billed Charges","neg_dollar:$4.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.61","52","","","Percent of Total Billed Charges","neg_dollar:$4.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","8.00",""
"DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN","J1100","HCPCS","63323-506-01","NDC","250","RC","","Facility","Outpatient","1","ML","9.10","9.10","","","","9.10","Fee Schedule","","","","","9.10","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","9.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.73","52","","","Percent of Total Billed Charges","neg_dollar:$4.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.73","52","","","Percent of Total Billed Charges","neg_dollar:$4.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.82","86","","","Percent of Total Billed Charges","neg_dollar:$7.82","6.36","70","","","Percent of Total Billed Charges","neg_dollar:$6.36","","52","","9.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.34;102% of Medicaid interim rate","6.82","75","","","Percent of Total Billed Charges","neg_dollar:$6.82","7.82","86","","","Percent of Total Billed Charges","neg_dollar:$7.82","6.36","70","","","Percent of Total Billed Charges","neg_dollar:$6.36","5.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.18;103.5% of Medicaid interim rate","9.10","150","","","Percent of Total Billed Charges","neg_dollar:$14.06;150% of Medicaid interim rate","7.28","80","","","Percent of Total Billed Charges","neg_dollar:$7.28;Percent of Total Billed Charges","8.37","92","","","Percent of Total Billed Charges","neg_dollar:$8.37","4.73","52","","","Percent of Total Billed Charges","neg_dollar:$4.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","9.10","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","9.00",""
"DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN","J1100","HCPCS","70069-021-01","NDC","636","RC","","Facility","Outpatient","1","ML","9.80","9.80","","","","9.80","Fee Schedule","","","","","9.80","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","5.09","52","","","Percent of Total Billed Charges","neg_dollar:$5.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.42","86","","","Percent of Total Billed Charges","neg_dollar:$8.42","6.86","70","","","Percent of Total Billed Charges","neg_dollar:$6.86","5.09","52","","","Percent of Total Billed Charges","neg_dollar:$5.09;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.75;102% of Medicaid interim rate","7.35","75","","","Percent of Total Billed Charges","neg_dollar:$7.35","8.42","86","","","Percent of Total Billed Charges","neg_dollar:$8.42","6.86","70","","","Percent of Total Billed Charges","neg_dollar:$6.86","5.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.58;103.5% of Medicaid interim rate","9.80","150","","","Percent of Total Billed Charges","neg_dollar:$15.15;150% of Medicaid interim rate","7.84","80","","","Percent of Total Billed Charges","neg_dollar:$7.84;Percent of Total Billed Charges","9.01","92","","","Percent of Total Billed Charges","neg_dollar:$9.01","5.09","52","","","Percent of Total Billed Charges","neg_dollar:$5.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.09","52","","","Percent of Total Billed Charges","neg_dollar:$5.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","9.00",""
"DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN","J1100","HCPCS","70069-021-01","NDC","250","RC","","Facility","Outpatient","10","ML","9.80","9.80","","","","9.80","Fee Schedule","","","","","9.80","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","9.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.09","52","","","Percent of Total Billed Charges","neg_dollar:$5.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.09","52","","","Percent of Total Billed Charges","neg_dollar:$5.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.42","86","","","Percent of Total Billed Charges","neg_dollar:$8.42","6.86","70","","","Percent of Total Billed Charges","neg_dollar:$6.86","","52","","9.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.75;102% of Medicaid interim rate","7.35","75","","","Percent of Total Billed Charges","neg_dollar:$7.35","8.42","86","","","Percent of Total Billed Charges","neg_dollar:$8.42","6.86","70","","","Percent of Total Billed Charges","neg_dollar:$6.86","5.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.58;103.5% of Medicaid interim rate","9.80","150","","","Percent of Total Billed Charges","neg_dollar:$15.15;150% of Medicaid interim rate","7.84","80","","","Percent of Total Billed Charges","neg_dollar:$7.84;Percent of Total Billed Charges","9.01","92","","","Percent of Total Billed Charges","neg_dollar:$9.01","5.09","52","","","Percent of Total Billed Charges","neg_dollar:$5.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","9.80","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","9.00",""
"DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN","J1100","HCPCS","63323-506-01","NDC","636","RC","","Facility","Outpatient","10","ML","0.75","0.75","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","101% of Medicare Fee Schedule","","","","0.75","Fee Schedule","","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% of Medicaid interim rate","0.56","75","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;103.5% of Medicaid interim rate","0.75","150","","","Percent of Total Billed Charges","neg_dollar:$1.15;150% of Medicaid interim rate","0.60","80","","","Percent of Total Billed Charges","neg_dollar:$0.60;Percent of Total Billed Charges","0.69","92","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN","J1100","HCPCS","63323-506-01","NDC","636","RC","","Facility","Outpatient","10","ML","9.10","9.10","","","","9.10","Fee Schedule","","","","","9.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","4.73","52","","","Percent of Total Billed Charges","neg_dollar:$4.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.82","86","","","Percent of Total Billed Charges","neg_dollar:$7.82","6.36","70","","","Percent of Total Billed Charges","neg_dollar:$6.36","4.73","52","","","Percent of Total Billed Charges","neg_dollar:$4.73;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.34;102% of Medicaid interim rate","6.82","75","","","Percent of Total Billed Charges","neg_dollar:$6.82","7.82","86","","","Percent of Total Billed Charges","neg_dollar:$7.82","6.36","70","","","Percent of Total Billed Charges","neg_dollar:$6.36","5.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.18;103.5% of Medicaid interim rate","9.10","150","","","Percent of Total Billed Charges","neg_dollar:$14.06;150% of Medicaid interim rate","7.28","80","","","Percent of Total Billed Charges","neg_dollar:$7.28;Percent of Total Billed Charges","8.37","92","","","Percent of Total Billed Charges","neg_dollar:$8.37","4.73","52","","","Percent of Total Billed Charges","neg_dollar:$4.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.73","52","","","Percent of Total Billed Charges","neg_dollar:$4.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","9.00",""
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","J1100","HCPCS","00641-6145-01","NDC","636","RC","","Facility","Outpatient","1","ML","12.59","12.59","","","","12.59","Fee Schedule","","","","","12.59","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","6.55","52","","","Percent of Total Billed Charges","neg_dollar:$6.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.59","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.59","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.83","86","","","Percent of Total Billed Charges","neg_dollar:$10.83","8.81","70","","","Percent of Total Billed Charges","neg_dollar:$8.81","6.55","52","","","Percent of Total Billed Charges","neg_dollar:$6.55;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.40;102% of Medicaid interim rate","9.44","75","","","Percent of Total Billed Charges","neg_dollar:$9.44","10.83","86","","","Percent of Total Billed Charges","neg_dollar:$10.83","8.81","70","","","Percent of Total Billed Charges","neg_dollar:$8.81","7.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.18;103.5% of Medicaid interim rate","12.59","150","","","Percent of Total Billed Charges","neg_dollar:$19.47;150% of Medicaid interim rate","10.07","80","","","Percent of Total Billed Charges","neg_dollar:$10.07;Percent of Total Billed Charges","11.58","92","","","Percent of Total Billed Charges","neg_dollar:$11.58","6.55","52","","","Percent of Total Billed Charges","neg_dollar:$6.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.55","52","","","Percent of Total Billed Charges","neg_dollar:$6.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","12.00",""
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","J1100","HCPCS","00641-6145-25","NDC","636","RC","","Facility","Outpatient","1","ML","16.37","16.37","","","","16.37","Fee Schedule","","","","","16.37","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","8.51","52","","","Percent of Total Billed Charges","neg_dollar:$8.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.08","86","","","Percent of Total Billed Charges","neg_dollar:$14.08","11.46","70","","","Percent of Total Billed Charges","neg_dollar:$11.46","8.51","52","","","Percent of Total Billed Charges","neg_dollar:$8.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.62;102% of Medicaid interim rate","12.28","75","","","Percent of Total Billed Charges","neg_dollar:$12.28","14.08","86","","","Percent of Total Billed Charges","neg_dollar:$14.08","11.46","70","","","Percent of Total Billed Charges","neg_dollar:$11.46","9.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.33;103.5% of Medicaid interim rate","16.37","150","","","Percent of Total Billed Charges","neg_dollar:$25.32;150% of Medicaid interim rate","13.10","80","","","Percent of Total Billed Charges","neg_dollar:$13.10;Percent of Total Billed Charges","15.06","92","","","Percent of Total Billed Charges","neg_dollar:$15.06","8.51","52","","","Percent of Total Billed Charges","neg_dollar:$8.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.51","52","","","Percent of Total Billed Charges","neg_dollar:$8.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","16.00",""
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","J1100","HCPCS","00641-6145-25","NDC","636","RC","","Facility","Outpatient","1","ML","0.25","0.25","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","101% of Medicare Fee Schedule","","","","0.25","Fee Schedule","","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% of Medicaid interim rate","0.18","75","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.25","150","","","Percent of Total Billed Charges","neg_dollar:$0.38;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN","J1100","HCPCS","00641-6145-01","NDC","250","RC","","Facility","Outpatient","1","ML","16.40","16.40","","","","16.40","Fee Schedule","","","","","16.40","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","16.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.10","86","","","Percent of Total Billed Charges","neg_dollar:$14.10","11.47","70","","","Percent of Total Billed Charges","neg_dollar:$11.47","","52","","16.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.63;102% of Medicaid interim rate","12.29","75","","","Percent of Total Billed Charges","neg_dollar:$12.29","14.10","86","","","Percent of Total Billed Charges","neg_dollar:$14.10","11.47","70","","","Percent of Total Billed Charges","neg_dollar:$11.47","9.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.34;103.5% of Medicaid interim rate","16.40","150","","","Percent of Total Billed Charges","neg_dollar:$25.35;150% of Medicaid interim rate","13.12","80","","","Percent of Total Billed Charges","neg_dollar:$13.12;Percent of Total Billed Charges","15.08","92","","","Percent of Total Billed Charges","neg_dollar:$15.08","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","16.40","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","16.00",""
"DILTIAZEM HCL 125 MG/25ML IV SOLN","J1163","HCPCS","00641-6015-01","NDC","636","RC","","Facility","Outpatient","1","UN","0.42","0.42","","","","0.42","Fee Schedule","","","","","0.42","Fee Schedule","101% of Medicare Fee Schedule","","","","0.42","Fee Schedule","","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","86","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.29","70","","","Percent of Total Billed Charges","neg_dollar:$0.29","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.24;102% of Medicaid interim rate","0.31","75","","","Percent of Total Billed Charges","neg_dollar:$0.31","0.36","86","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.29","70","","","Percent of Total Billed Charges","neg_dollar:$0.29","0.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.24;103.5% of Medicaid interim rate","0.42","150","","","Percent of Total Billed Charges","neg_dollar:$0.65;150% of Medicaid interim rate","0.33","80","","","Percent of Total Billed Charges","neg_dollar:$0.33;Percent of Total Billed Charges","0.38","92","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DILTIAZEM HCL 125 MG/25ML IV SOLN","J1163","HCPCS","00641-6015-10","NDC","636","RC","","Facility","Outpatient","1","UN","0.42","0.42","","","","0.42","Fee Schedule","","","","","0.42","Fee Schedule","101% of Medicare Fee Schedule","","","","0.42","Fee Schedule","","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","86","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.29","70","","","Percent of Total Billed Charges","neg_dollar:$0.29","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.24;102% of Medicaid interim rate","0.31","75","","","Percent of Total Billed Charges","neg_dollar:$0.31","0.36","86","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.29","70","","","Percent of Total Billed Charges","neg_dollar:$0.29","0.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.24;103.5% of Medicaid interim rate","0.42","150","","","Percent of Total Billed Charges","neg_dollar:$0.65;150% of Medicaid interim rate","0.33","80","","","Percent of Total Billed Charges","neg_dollar:$0.33;Percent of Total Billed Charges","0.38","92","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","52","","","Percent of Total Billed Charges","neg_dollar:$0.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DILTIAZEM HCL 25 MG/5ML IV SOLN","J1163","HCPCS","70860-301-41","NDC","636","RC","","Facility","Outpatient","1","UN","2.55","2.55","","","","2.55","Fee Schedule","","","","","2.55","Fee Schedule","101% of Medicare Fee Schedule","","","","2.55","Fee Schedule","","1.33","52","","","Percent of Total Billed Charges","neg_dollar:$1.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.20","86","","","Percent of Total Billed Charges","neg_dollar:$2.20","1.79","70","","","Percent of Total Billed Charges","neg_dollar:$1.79","1.33","52","","","Percent of Total Billed Charges","neg_dollar:$1.33;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.50;102% of Medicaid interim rate","1.91","75","","","Percent of Total Billed Charges","neg_dollar:$1.91","2.20","86","","","Percent of Total Billed Charges","neg_dollar:$2.20","1.79","70","","","Percent of Total Billed Charges","neg_dollar:$1.79","1.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.45;103.5% of Medicaid interim rate","2.55","150","","","Percent of Total Billed Charges","neg_dollar:$3.95;150% of Medicaid interim rate","2.04","80","","","Percent of Total Billed Charges","neg_dollar:$2.04;Percent of Total Billed Charges","2.35","92","","","Percent of Total Billed Charges","neg_dollar:$2.35","1.33","52","","","Percent of Total Billed Charges","neg_dollar:$1.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","52","","","Percent of Total Billed Charges","neg_dollar:$1.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"DILTIAZEM HCL 25 MG/5ML IV SOLN","J1163","HCPCS","00641-6013-01","NDC","636","RC","","Facility","Outpatient","1","UN","2.32","2.32","","","","2.32","Fee Schedule","","","","","2.32","Fee Schedule","101% of Medicare Fee Schedule","","","","2.32","Fee Schedule","","1.20","52","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.99","86","","","Percent of Total Billed Charges","neg_dollar:$1.99","1.62","70","","","Percent of Total Billed Charges","neg_dollar:$1.62","1.20","52","","","Percent of Total Billed Charges","neg_dollar:$1.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.36;102% of Medicaid interim rate","1.74","75","","","Percent of Total Billed Charges","neg_dollar:$1.74","1.99","86","","","Percent of Total Billed Charges","neg_dollar:$1.99","1.62","70","","","Percent of Total Billed Charges","neg_dollar:$1.62","1.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.32;103.5% of Medicaid interim rate","2.32","150","","","Percent of Total Billed Charges","neg_dollar:$3.59;150% of Medicaid interim rate","1.86","80","","","Percent of Total Billed Charges","neg_dollar:$1.86;Percent of Total Billed Charges","2.13","92","","","Percent of Total Billed Charges","neg_dollar:$2.13","1.20","52","","","Percent of Total Billed Charges","neg_dollar:$1.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","52","","","Percent of Total Billed Charges","neg_dollar:$1.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","J1170","HCPCS","00409-1283-03","NDC","250","RC","","Facility","Outpatient","1","ML","89.10","89.10","","","","4.00","Fee Schedule","","","","","46.00","Fee Schedule","","","","","4.00","Fee Schedule","","","52","","89.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.33","52","","","Percent of Total Billed Charges","neg_dollar:$46.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.33","52","","","Percent of Total Billed Charges","neg_dollar:$46.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.62","86","","","Percent of Total Billed Charges","neg_dollar:$76.62","62.37","70","","","Percent of Total Billed Charges","neg_dollar:$62.37","","52","","72.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.34;102% of Medicaid interim rate","66.82","75","","","Percent of Total Billed Charges","neg_dollar:$66.82","76.62","86","","","Percent of Total Billed Charges","neg_dollar:$76.62","62.37","70","","","Percent of Total Billed Charges","neg_dollar:$62.37","50.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.78;103.5% of Medicaid interim rate","89.10","150","","","Percent of Total Billed Charges","neg_dollar:$137.75;150% of Medicaid interim rate","71.28","80","","","Percent of Total Billed Charges","neg_dollar:$71.28;Percent of Total Billed Charges","81.97","92","","","Percent of Total Billed Charges","neg_dollar:$81.97","46.33","52","","","Percent of Total Billed Charges","neg_dollar:$46.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","89.00",""
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","J1170","HCPCS","00409-1283-31","NDC","250","RC","","Facility","Outpatient","1","ML","90.10","90.10","","","","4.00","Fee Schedule","","","","","46.00","Fee Schedule","","","","","4.00","Fee Schedule","","","52","","90.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.85","52","","","Percent of Total Billed Charges","neg_dollar:$46.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.85","52","","","Percent of Total Billed Charges","neg_dollar:$46.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","77.48","86","","","Percent of Total Billed Charges","neg_dollar:$77.48","63.06","70","","","Percent of Total Billed Charges","neg_dollar:$63.06","","52","","72.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.93;102% of Medicaid interim rate","67.57","75","","","Percent of Total Billed Charges","neg_dollar:$67.57","77.48","86","","","Percent of Total Billed Charges","neg_dollar:$77.48","63.06","70","","","Percent of Total Billed Charges","neg_dollar:$63.06","51.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.35;103.5% of Medicaid interim rate","90.10","150","","","Percent of Total Billed Charges","neg_dollar:$139.29;150% of Medicaid interim rate","72.08","80","","","Percent of Total Billed Charges","neg_dollar:$72.08;Percent of Total Billed Charges","82.89","92","","","Percent of Total Billed Charges","neg_dollar:$82.89","46.85","52","","","Percent of Total Billed Charges","neg_dollar:$46.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","90.00",""
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","J1170","HCPCS","00409-1283-03","NDC","636","RC","","Facility","Outpatient","1","ML","91.02","91.02","","","","4.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","4.00","Fee Schedule","","47.33","52","","","Percent of Total Billed Charges","neg_dollar:$47.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.27","86","","","Percent of Total Billed Charges","neg_dollar:$78.27","63.71","70","","","Percent of Total Billed Charges","neg_dollar:$63.71","47.33","52","","","Percent of Total Billed Charges","neg_dollar:$47.33;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.47;102% of Medicaid interim rate","68.26","75","","","Percent of Total Billed Charges","neg_dollar:$68.26","78.27","86","","","Percent of Total Billed Charges","neg_dollar:$78.27","63.71","70","","","Percent of Total Billed Charges","neg_dollar:$63.71","51.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.88;103.5% of Medicaid interim rate","91.02","150","","","Percent of Total Billed Charges","neg_dollar:$140.72;150% of Medicaid interim rate","72.81","80","","","Percent of Total Billed Charges","neg_dollar:$72.81;Percent of Total Billed Charges","83.73","92","","","Percent of Total Billed Charges","neg_dollar:$83.73","47.33","52","","","Percent of Total Billed Charges","neg_dollar:$47.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.33","52","","","Percent of Total Billed Charges","neg_dollar:$47.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","91.00",""
"HYDROMORPHONE HCL 1MG/ML INJECTION","J1170","HCPCS","00409-1283-03","NDC","636","RC","","Facility","Outpatient","1","ML","92.70","92.70","","","","4.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","4.00","Fee Schedule","","48.20","52","","","Percent of Total Billed Charges","neg_dollar:$48.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","92.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","92.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","79.72","86","","","Percent of Total Billed Charges","neg_dollar:$79.72","64.89","70","","","Percent of Total Billed Charges","neg_dollar:$64.89","48.20","52","","","Percent of Total Billed Charges","neg_dollar:$48.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","54.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.46;102% of Medicaid interim rate","69.52","75","","","Percent of Total Billed Charges","neg_dollar:$69.52","79.72","86","","","Percent of Total Billed Charges","neg_dollar:$79.72","64.89","70","","","Percent of Total Billed Charges","neg_dollar:$64.89","52.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.83;103.5% of Medicaid interim rate","92.70","150","","","Percent of Total Billed Charges","neg_dollar:$143.31;150% of Medicaid interim rate","74.16","80","","","Percent of Total Billed Charges","neg_dollar:$74.16;Percent of Total Billed Charges","85.28","92","","","Percent of Total Billed Charges","neg_dollar:$85.28","48.20","52","","","Percent of Total Billed Charges","neg_dollar:$48.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.20","52","","","Percent of Total Billed Charges","neg_dollar:$48.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","92.00",""
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","J1170","HCPCS","00409-1283-31","NDC","636","RC","","Facility","Outpatient","1","ML","92.70","92.70","","","","4.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","4.00","Fee Schedule","","48.20","52","","","Percent of Total Billed Charges","neg_dollar:$48.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","92.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","92.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","79.72","86","","","Percent of Total Billed Charges","neg_dollar:$79.72","64.89","70","","","Percent of Total Billed Charges","neg_dollar:$64.89","48.20","52","","","Percent of Total Billed Charges","neg_dollar:$48.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","54.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.46;102% of Medicaid interim rate","69.52","75","","","Percent of Total Billed Charges","neg_dollar:$69.52","79.72","86","","","Percent of Total Billed Charges","neg_dollar:$79.72","64.89","70","","","Percent of Total Billed Charges","neg_dollar:$64.89","52.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.83;103.5% of Medicaid interim rate","92.70","150","","","Percent of Total Billed Charges","neg_dollar:$143.31;150% of Medicaid interim rate","74.16","80","","","Percent of Total Billed Charges","neg_dollar:$74.16;Percent of Total Billed Charges","85.28","92","","","Percent of Total Billed Charges","neg_dollar:$85.28","48.20","52","","","Percent of Total Billed Charges","neg_dollar:$48.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.20","52","","","Percent of Total Billed Charges","neg_dollar:$48.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","92.00",""
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","J1171","HCPCS","00409-1283-31","NDC","250","RC","","Facility","Outpatient","1","ML","15.10","15.10","","","","15.10","Fee Schedule","","","","","15.10","Fee Schedule","","","","","15.10","Fee Schedule","","","52","","15.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.85","52","","","Percent of Total Billed Charges","neg_dollar:$7.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.85","52","","","Percent of Total Billed Charges","neg_dollar:$7.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.98","86","","","Percent of Total Billed Charges","neg_dollar:$12.98","10.57","70","","","Percent of Total Billed Charges","neg_dollar:$10.57","","52","","15.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.87;102% of Medicaid interim rate","11.32","75","","","Percent of Total Billed Charges","neg_dollar:$11.32","12.98","86","","","Percent of Total Billed Charges","neg_dollar:$12.98","10.57","70","","","Percent of Total Billed Charges","neg_dollar:$10.57","8.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.60;103.5% of Medicaid interim rate","15.10","150","","","Percent of Total Billed Charges","neg_dollar:$23.35;150% of Medicaid interim rate","12.08","80","","","Percent of Total Billed Charges","neg_dollar:$12.08;Percent of Total Billed Charges","13.89","92","","","Percent of Total Billed Charges","neg_dollar:$13.89","7.85","52","","","Percent of Total Billed Charges","neg_dollar:$7.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","15.10","Fee Schedule","","7.00","15.00",""
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","J1171","HCPCS","00409-1283-03","NDC","636","RC","","Facility","Outpatient","1","ML","15.97","15.97","","","","15.97","Fee Schedule","","","","","15.97","Fee Schedule","101% of Medicare Fee Schedule","","","","15.97","Fee Schedule","","8.30","52","","","Percent of Total Billed Charges","neg_dollar:$8.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","15.97","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","15.97","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.73","86","","","Percent of Total Billed Charges","neg_dollar:$13.73","11.18","70","","","Percent of Total Billed Charges","neg_dollar:$11.18","8.30","52","","","Percent of Total Billed Charges","neg_dollar:$8.30;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.38;102% of Medicaid interim rate","11.98","75","","","Percent of Total Billed Charges","neg_dollar:$11.98","13.73","86","","","Percent of Total Billed Charges","neg_dollar:$13.73","11.18","70","","","Percent of Total Billed Charges","neg_dollar:$11.18","9.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.10;103.5% of Medicaid interim rate","15.97","150","","","Percent of Total Billed Charges","neg_dollar:$24.69;150% of Medicaid interim rate","12.78","80","","","Percent of Total Billed Charges","neg_dollar:$12.78;Percent of Total Billed Charges","14.69","92","","","Percent of Total Billed Charges","neg_dollar:$14.69","8.30","52","","","Percent of Total Billed Charges","neg_dollar:$8.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.30","52","","","Percent of Total Billed Charges","neg_dollar:$8.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","15.00",""
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","J1171","HCPCS","00409-1283-31","NDC","636","RC","","Facility","Outpatient","1","ML","10.03","10.03","","","","10.03","Fee Schedule","","","","","10.03","Fee Schedule","101% of Medicare Fee Schedule","","","","10.03","Fee Schedule","","5.21","52","","","Percent of Total Billed Charges","neg_dollar:$5.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.62","86","","","Percent of Total Billed Charges","neg_dollar:$8.62","7.02","70","","","Percent of Total Billed Charges","neg_dollar:$7.02","5.21","52","","","Percent of Total Billed Charges","neg_dollar:$5.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.89;102% of Medicaid interim rate","7.52","75","","","Percent of Total Billed Charges","neg_dollar:$7.52","8.62","86","","","Percent of Total Billed Charges","neg_dollar:$8.62","7.02","70","","","Percent of Total Billed Charges","neg_dollar:$7.02","5.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.71;103.5% of Medicaid interim rate","10.03","150","","","Percent of Total Billed Charges","neg_dollar:$15.50;150% of Medicaid interim rate","8.02","80","","","Percent of Total Billed Charges","neg_dollar:$8.02;Percent of Total Billed Charges","9.22","92","","","Percent of Total Billed Charges","neg_dollar:$9.22","5.21","52","","","Percent of Total Billed Charges","neg_dollar:$5.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.21","52","","","Percent of Total Billed Charges","neg_dollar:$5.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","J1171","HCPCS","00409-1283-03","NDC","250","RC","","Facility","Outpatient","1","ML","18.02","18.02","","","","18.02","Fee Schedule","","","","","18.02","Fee Schedule","","","","","18.02","Fee Schedule","","","52","","18.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.37","52","","","Percent of Total Billed Charges","neg_dollar:$9.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.37","52","","","Percent of Total Billed Charges","neg_dollar:$9.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.49","86","","","Percent of Total Billed Charges","neg_dollar:$15.49","12.61","70","","","Percent of Total Billed Charges","neg_dollar:$12.61","","52","","18.02","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.58;102% of Medicaid interim rate","13.51","75","","","Percent of Total Billed Charges","neg_dollar:$13.51","15.49","86","","","Percent of Total Billed Charges","neg_dollar:$15.49","12.61","70","","","Percent of Total Billed Charges","neg_dollar:$12.61","10.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.27;103.5% of Medicaid interim rate","18.02","150","","","Percent of Total Billed Charges","neg_dollar:$27.85;150% of Medicaid interim rate","14.41","80","","","Percent of Total Billed Charges","neg_dollar:$14.41;Percent of Total Billed Charges","16.57","92","","","Percent of Total Billed Charges","neg_dollar:$16.57","9.37","52","","","Percent of Total Billed Charges","neg_dollar:$9.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","18.02","Fee Schedule","","9.00","18.00",""
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","J1171","HCPCS","00409-1283-03","NDC","636","RC","","Facility","Outpatient","1","ML","15.71","15.71","","","","15.71","Fee Schedule","","","","","15.71","Fee Schedule","101% of Medicare Fee Schedule","","","","15.71","Fee Schedule","","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","15.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","15.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.51","86","","","Percent of Total Billed Charges","neg_dollar:$13.51","10.99","70","","","Percent of Total Billed Charges","neg_dollar:$10.99","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.23;102% of Medicaid interim rate","11.78","75","","","Percent of Total Billed Charges","neg_dollar:$11.78","13.51","86","","","Percent of Total Billed Charges","neg_dollar:$13.51","10.99","70","","","Percent of Total Billed Charges","neg_dollar:$10.99","8.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.95;103.5% of Medicaid interim rate","15.71","150","","","Percent of Total Billed Charges","neg_dollar:$24.29;150% of Medicaid interim rate","12.56","80","","","Percent of Total Billed Charges","neg_dollar:$12.56;Percent of Total Billed Charges","14.45","92","","","Percent of Total Billed Charges","neg_dollar:$14.45","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","15.00",""
"HYDROMORPHONE HCL 1 MG/ML IJ SOLN","J1171","HCPCS","00409-1283-03","NDC","250","RC","","Facility","Outpatient","1","ML","12.70","12.70","","","","12.70","Fee Schedule","","","","","12.70","Fee Schedule","","","","","12.70","Fee Schedule","","","52","","12.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.60","52","","","Percent of Total Billed Charges","neg_dollar:$6.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.60","52","","","Percent of Total Billed Charges","neg_dollar:$6.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.92","86","","","Percent of Total Billed Charges","neg_dollar:$10.92","8.89","70","","","Percent of Total Billed Charges","neg_dollar:$8.89","","52","","12.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.46;102% of Medicaid interim rate","9.52","75","","","Percent of Total Billed Charges","neg_dollar:$9.52","10.92","86","","","Percent of Total Billed Charges","neg_dollar:$10.92","8.89","70","","","Percent of Total Billed Charges","neg_dollar:$8.89","7.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.24;103.5% of Medicaid interim rate","12.70","150","","","Percent of Total Billed Charges","neg_dollar:$19.64;150% of Medicaid interim rate","10.16","80","","","Percent of Total Billed Charges","neg_dollar:$10.16;Percent of Total Billed Charges","11.68","92","","","Percent of Total Billed Charges","neg_dollar:$11.68","6.60","52","","","Percent of Total Billed Charges","neg_dollar:$6.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.70","Fee Schedule","","6.00","12.00",""
"DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN","J1200","HCPCS","63323-664-01","NDC","250","RC","","Facility","Outpatient","1","ML","91.05","91.05","","","","1.00","Fee Schedule","","","","","46.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","91.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.34","52","","","Percent of Total Billed Charges","neg_dollar:$47.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.34","52","","","Percent of Total Billed Charges","neg_dollar:$47.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.30","86","","","Percent of Total Billed Charges","neg_dollar:$78.30","63.73","70","","","Percent of Total Billed Charges","neg_dollar:$63.73","","52","","72.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.49;102% of Medicaid interim rate","68.28","75","","","Percent of Total Billed Charges","neg_dollar:$68.28","78.30","86","","","Percent of Total Billed Charges","neg_dollar:$78.30","63.73","70","","","Percent of Total Billed Charges","neg_dollar:$63.73","51.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.89;103.5% of Medicaid interim rate","91.05","150","","","Percent of Total Billed Charges","neg_dollar:$140.76;150% of Medicaid interim rate","72.84","80","","","Percent of Total Billed Charges","neg_dollar:$72.84;Percent of Total Billed Charges","83.76","92","","","Percent of Total Billed Charges","neg_dollar:$83.76","47.34","52","","","Percent of Total Billed Charges","neg_dollar:$47.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN","J1200","HCPCS","63323-664-01","NDC","636","RC","","Facility","Outpatient","1","ML","91.67","91.67","","","","1.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","47.66","52","","","Percent of Total Billed Charges","neg_dollar:$47.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.83","86","","","Percent of Total Billed Charges","neg_dollar:$78.83","64.16","70","","","Percent of Total Billed Charges","neg_dollar:$64.16","47.66","52","","","Percent of Total Billed Charges","neg_dollar:$47.66;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.85;102% of Medicaid interim rate","68.75","75","","","Percent of Total Billed Charges","neg_dollar:$68.75","78.83","86","","","Percent of Total Billed Charges","neg_dollar:$78.83","64.16","70","","","Percent of Total Billed Charges","neg_dollar:$64.16","52.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.25;103.5% of Medicaid interim rate","91.67","150","","","Percent of Total Billed Charges","neg_dollar:$141.72;150% of Medicaid interim rate","73.33","80","","","Percent of Total Billed Charges","neg_dollar:$73.33;Percent of Total Billed Charges","84.33","92","","","Percent of Total Billed Charges","neg_dollar:$84.33","47.66","52","","","Percent of Total Billed Charges","neg_dollar:$47.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.66","52","","","Percent of Total Billed Charges","neg_dollar:$47.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"FAMOTIDINE (PF) 20 MG/2ML IV SOLN","J1308","HCPCS","67457-433-00","NDC","250","RC","","Facility","Outpatient","2","ML","1.11","1.11","","","","1.11","Fee Schedule","","","","","1.11","Fee Schedule","","","","","1.11","Fee Schedule","","","52","","1.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","86","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","","52","","1.11","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% of Medicaid interim rate","0.83","75","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.95","86","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;103.5% of Medicaid interim rate","1.11","150","","","Percent of Total Billed Charges","neg_dollar:$1.72;150% of Medicaid interim rate","0.89","80","","","Percent of Total Billed Charges","neg_dollar:$0.89;Percent of Total Billed Charges","1.02","92","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.11","Fee Schedule","","1.00","1.00",""
"FAMOTIDINE (PF) 20 MG/2ML IV SOLN","J1308","HCPCS","67457-433-22","NDC","636","RC","","Facility","Outpatient","2","ML","1.11","1.11","","","","1.11","Fee Schedule","","","","","1.11","Fee Schedule","101% of Medicare Fee Schedule","","","","1.11","Fee Schedule","","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","86","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% of Medicaid interim rate","0.83","75","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.95","86","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;103.5% of Medicaid interim rate","1.11","150","","","Percent of Total Billed Charges","neg_dollar:$1.72;150% of Medicaid interim rate","0.89","80","","","Percent of Total Billed Charges","neg_dollar:$0.89;Percent of Total Billed Charges","1.02","92","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FAMOTIDINE (PF) 20 MG/2ML IV SOLN","J1308","HCPCS","67457-433-00","NDC","636","RC","","Facility","Outpatient","2","ML","0.91","0.91","","","","0.91","Fee Schedule","","","","","0.91","Fee Schedule","101% of Medicare Fee Schedule","","","","0.91","Fee Schedule","","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.64","70","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% of Medicaid interim rate","0.68","75","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.64","70","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;103.5% of Medicaid interim rate","0.91","150","","","Percent of Total Billed Charges","neg_dollar:$1.41;150% of Medicaid interim rate","0.73","80","","","Percent of Total Billed Charges","neg_dollar:$0.73;Percent of Total Billed Charges","0.84","92","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN","J1439","HCPCS","00517-0650-01","NDC","636","RC","","Facility","Outpatient","1","UN","4.04","4.04","","","","4.04","Fee Schedule","","","","","4.04","Fee Schedule","101% of Medicare Fee Schedule","","","","4.04","Fee Schedule","","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.47","86","","","Percent of Total Billed Charges","neg_dollar:$3.47","2.83","70","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.37;102% of Medicaid interim rate","3.03","75","","","Percent of Total Billed Charges","neg_dollar:$3.03","3.47","86","","","Percent of Total Billed Charges","neg_dollar:$3.47","2.83","70","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.30;103.5% of Medicaid interim rate","4.04","150","","","Percent of Total Billed Charges","neg_dollar:$6.25;150% of Medicaid interim rate","3.23","80","","","Percent of Total Billed Charges","neg_dollar:$3.23;Percent of Total Billed Charges","3.72","92","","","Percent of Total Billed Charges","neg_dollar:$3.72","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN","J1450","HCPCS","25021-184-82","NDC","250","RC","","Facility","Outpatient","1","UN","91.90","91.90","","","","37.00","Fee Schedule","","","","","51.00","Fee Schedule","","","","","39.00","Fee Schedule","","","52","","91.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.78","52","","","Percent of Total Billed Charges","neg_dollar:$47.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.78","52","","","Percent of Total Billed Charges","neg_dollar:$47.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","79.03","86","","","Percent of Total Billed Charges","neg_dollar:$79.03","64.33","70","","","Percent of Total Billed Charges","neg_dollar:$64.33","","52","","79.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.99;102% of Medicaid interim rate","68.92","75","","","Percent of Total Billed Charges","neg_dollar:$68.92","79.03","86","","","Percent of Total Billed Charges","neg_dollar:$79.03","64.33","70","","","Percent of Total Billed Charges","neg_dollar:$64.33","52.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.38;103.5% of Medicaid interim rate","91.90","150","","","Percent of Total Billed Charges","neg_dollar:$142.08;150% of Medicaid interim rate","73.52","80","","","Percent of Total Billed Charges","neg_dollar:$73.52;Percent of Total Billed Charges","84.54","92","","","Percent of Total Billed Charges","neg_dollar:$84.54","47.78","52","","","Percent of Total Billed Charges","neg_dollar:$47.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","37.00","91.00",""
"PRIVIGEN 10 GM/100ML IV SOLN","J1459","HCPCS","44206-437-10","NDC","636","RC","","Facility","Outpatient","10","UN","190.46","190.46","","","","190.46","Fee Schedule","","","","","190.46","Fee Schedule","101% of Medicare Fee Schedule","","","","190.46","Fee Schedule","","99.04","52","","","Percent of Total Billed Charges","neg_dollar:$99.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","190.46","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","190.46","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","163.80","86","","","Percent of Total Billed Charges","neg_dollar:$163.80","133.32","70","","","Percent of Total Billed Charges","neg_dollar:$133.32","99.04","52","","","Percent of Total Billed Charges","neg_dollar:$99.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","111.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$111.89;102% of Medicaid interim rate","142.85","75","","","Percent of Total Billed Charges","neg_dollar:$142.85","163.80","86","","","Percent of Total Billed Charges","neg_dollar:$163.80","133.32","70","","","Percent of Total Billed Charges","neg_dollar:$133.32","108.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$108.56;103.5% of Medicaid interim rate","190.46","150","","","Percent of Total Billed Charges","neg_dollar:$294.47;150% of Medicaid interim rate","152.37","80","","","Percent of Total Billed Charges","neg_dollar:$152.37;Percent of Total Billed Charges","175.23","92","","","Percent of Total Billed Charges","neg_dollar:$175.23","99.04","52","","","Percent of Total Billed Charges","neg_dollar:$99.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","99.04","52","","","Percent of Total Billed Charges","neg_dollar:$99.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","99.00","190.00",""
"PRIVIGEN 10 GM/100ML IV SOLN","J1459","HCPCS","44206-437-10","NDC","636","RC","","Facility","Outpatient","10","UN","185.41","185.41","","","","185.41","Fee Schedule","","","","","185.41","Fee Schedule","101% of Medicare Fee Schedule","","","","185.41","Fee Schedule","","96.41","52","","","Percent of Total Billed Charges","neg_dollar:$96.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","185.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","185.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","159.45","86","","","Percent of Total Billed Charges","neg_dollar:$159.45","129.79","70","","","Percent of Total Billed Charges","neg_dollar:$129.79","96.41","52","","","Percent of Total Billed Charges","neg_dollar:$96.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","108.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$108.93;102% of Medicaid interim rate","139.06","75","","","Percent of Total Billed Charges","neg_dollar:$139.06","159.45","86","","","Percent of Total Billed Charges","neg_dollar:$159.45","129.79","70","","","Percent of Total Billed Charges","neg_dollar:$129.79","105.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$105.68;103.5% of Medicaid interim rate","185.41","150","","","Percent of Total Billed Charges","neg_dollar:$286.66;150% of Medicaid interim rate","148.33","80","","","Percent of Total Billed Charges","neg_dollar:$148.33;Percent of Total Billed Charges","170.58","92","","","Percent of Total Billed Charges","neg_dollar:$170.58","96.41","52","","","Percent of Total Billed Charges","neg_dollar:$96.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","96.41","52","","","Percent of Total Billed Charges","neg_dollar:$96.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","96.00","185.00",""
"PRIVIGEN 20 GM/200ML IV SOLN","J1459","HCPCS","44206-438-20","NDC","636","RC","","Facility","Outpatient","1","UN","183.22","183.22","","","","183.22","Fee Schedule","","","","","183.22","Fee Schedule","101% of Medicare Fee Schedule","","","","183.22","Fee Schedule","","95.27","52","","","Percent of Total Billed Charges","neg_dollar:$95.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","183.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","183.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","157.57","86","","","Percent of Total Billed Charges","neg_dollar:$157.57","128.25","70","","","Percent of Total Billed Charges","neg_dollar:$128.25","95.27","52","","","Percent of Total Billed Charges","neg_dollar:$95.27;105% Medicare Outpatient Cost to Charge Ratio of 52%","107.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$107.64;102% of Medicaid interim rate","137.42","75","","","Percent of Total Billed Charges","neg_dollar:$137.42","157.57","86","","","Percent of Total Billed Charges","neg_dollar:$157.57","128.25","70","","","Percent of Total Billed Charges","neg_dollar:$128.25","104.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$104.43;103.5% of Medicaid interim rate","183.22","150","","","Percent of Total Billed Charges","neg_dollar:$283.27;150% of Medicaid interim rate","146.58","80","","","Percent of Total Billed Charges","neg_dollar:$146.58;Percent of Total Billed Charges","168.56","92","","","Percent of Total Billed Charges","neg_dollar:$168.56","95.27","52","","","Percent of Total Billed Charges","neg_dollar:$95.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","95.27","52","","","Percent of Total Billed Charges","neg_dollar:$95.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","95.00","183.00",""
"IMMUNE GLOBULIN (HUMAN) 40 GM/400ML IV SOLN","J1459","HCPCS","44206-439-40","NDC","636","RC","","Facility","Outpatient","1","UN","182.13","182.13","","","","182.13","Fee Schedule","","","","","182.13","Fee Schedule","101% of Medicare Fee Schedule","","","","182.13","Fee Schedule","","94.70","52","","","Percent of Total Billed Charges","neg_dollar:$94.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","156.63","86","","","Percent of Total Billed Charges","neg_dollar:$156.63","127.49","70","","","Percent of Total Billed Charges","neg_dollar:$127.49","94.70","52","","","Percent of Total Billed Charges","neg_dollar:$94.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","107.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$107;102% of Medicaid interim rate","136.60","75","","","Percent of Total Billed Charges","neg_dollar:$136.60","156.63","86","","","Percent of Total Billed Charges","neg_dollar:$156.63","127.49","70","","","Percent of Total Billed Charges","neg_dollar:$127.49","103.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$103.81;103.5% of Medicaid interim rate","182.13","150","","","Percent of Total Billed Charges","neg_dollar:$281.58;150% of Medicaid interim rate","145.70","80","","","Percent of Total Billed Charges","neg_dollar:$145.70;Percent of Total Billed Charges","167.56","92","","","Percent of Total Billed Charges","neg_dollar:$167.56","94.70","52","","","Percent of Total Billed Charges","neg_dollar:$94.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.70","52","","","Percent of Total Billed Charges","neg_dollar:$94.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.00","182.00",""
"PRIVIGEN 5 GM/50ML IV SOLN","J1459","HCPCS","44206-438-20","NDC","636","RC","","Facility","Outpatient","1","UN","184.13","184.13","","","","184.13","Fee Schedule","","","","","184.13","Fee Schedule","101% of Medicare Fee Schedule","","","","184.13","Fee Schedule","","95.75","52","","","Percent of Total Billed Charges","neg_dollar:$95.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","184.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","184.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","158.35","86","","","Percent of Total Billed Charges","neg_dollar:$158.35","128.89","70","","","Percent of Total Billed Charges","neg_dollar:$128.89","95.75","52","","","Percent of Total Billed Charges","neg_dollar:$95.75;105% Medicare Outpatient Cost to Charge Ratio of 52%","108.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$108.18;102% of Medicaid interim rate","138.10","75","","","Percent of Total Billed Charges","neg_dollar:$138.10","158.35","86","","","Percent of Total Billed Charges","neg_dollar:$158.35","128.89","70","","","Percent of Total Billed Charges","neg_dollar:$128.89","104.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$104.95;103.5% of Medicaid interim rate","184.13","150","","","Percent of Total Billed Charges","neg_dollar:$284.68;150% of Medicaid interim rate","147.30","80","","","Percent of Total Billed Charges","neg_dollar:$147.30;Percent of Total Billed Charges","169.40","92","","","Percent of Total Billed Charges","neg_dollar:$169.40","95.75","52","","","Percent of Total Billed Charges","neg_dollar:$95.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","95.75","52","","","Percent of Total Billed Charges","neg_dollar:$95.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","95.00","184.00",""
"PRIVIGEN 5 GM/50ML IV SOLN","J1459","HCPCS","44206-439-40","NDC","636","RC","","Facility","Outpatient","1","UN","182.13","182.13","","","","182.13","Fee Schedule","","","","","182.13","Fee Schedule","101% of Medicare Fee Schedule","","","","182.13","Fee Schedule","","94.70","52","","","Percent of Total Billed Charges","neg_dollar:$94.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","156.63","86","","","Percent of Total Billed Charges","neg_dollar:$156.63","127.49","70","","","Percent of Total Billed Charges","neg_dollar:$127.49","94.70","52","","","Percent of Total Billed Charges","neg_dollar:$94.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","107.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$107;102% of Medicaid interim rate","136.60","75","","","Percent of Total Billed Charges","neg_dollar:$136.60","156.63","86","","","Percent of Total Billed Charges","neg_dollar:$156.63","127.49","70","","","Percent of Total Billed Charges","neg_dollar:$127.49","103.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$103.81;103.5% of Medicaid interim rate","182.13","150","","","Percent of Total Billed Charges","neg_dollar:$281.58;150% of Medicaid interim rate","145.70","80","","","Percent of Total Billed Charges","neg_dollar:$145.70;Percent of Total Billed Charges","167.56","92","","","Percent of Total Billed Charges","neg_dollar:$167.56","94.70","52","","","Percent of Total Billed Charges","neg_dollar:$94.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.70","52","","","Percent of Total Billed Charges","neg_dollar:$94.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.00","182.00",""
"PRIVIGEN 5 GM/50ML IV SOLN","J1459","HCPCS","44206-436-05","NDC","636","RC","","Facility","Outpatient","1","UN","189.03","189.03","","","","189.03","Fee Schedule","","","","","189.03","Fee Schedule","101% of Medicare Fee Schedule","","","","189.03","Fee Schedule","","98.29","52","","","Percent of Total Billed Charges","neg_dollar:$98.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","189.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","189.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","162.57","86","","","Percent of Total Billed Charges","neg_dollar:$162.57","132.32","70","","","Percent of Total Billed Charges","neg_dollar:$132.32","98.29","52","","","Percent of Total Billed Charges","neg_dollar:$98.29;105% Medicare Outpatient Cost to Charge Ratio of 52%","111.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$111.05;102% of Medicaid interim rate","141.77","75","","","Percent of Total Billed Charges","neg_dollar:$141.77","162.57","86","","","Percent of Total Billed Charges","neg_dollar:$162.57","132.32","70","","","Percent of Total Billed Charges","neg_dollar:$132.32","107.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$107.74;103.5% of Medicaid interim rate","189.03","150","","","Percent of Total Billed Charges","neg_dollar:$292.25;150% of Medicaid interim rate","151.22","80","","","Percent of Total Billed Charges","neg_dollar:$151.22;Percent of Total Billed Charges","173.91","92","","","Percent of Total Billed Charges","neg_dollar:$173.91","98.29","52","","","Percent of Total Billed Charges","neg_dollar:$98.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","98.29","52","","","Percent of Total Billed Charges","neg_dollar:$98.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","98.00","189.00",""
"PRIVIGEN 5 GM/50ML IV SOLN","J1459","HCPCS","44206-437-10","NDC","636","RC","","Facility","Outpatient","1","UN","181.04","181.04","","","","181.04","Fee Schedule","","","","","181.04","Fee Schedule","101% of Medicare Fee Schedule","","","","181.04","Fee Schedule","","94.14","52","","","Percent of Total Billed Charges","neg_dollar:$94.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","181.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","181.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","155.69","86","","","Percent of Total Billed Charges","neg_dollar:$155.69","126.72","70","","","Percent of Total Billed Charges","neg_dollar:$126.72","94.14","52","","","Percent of Total Billed Charges","neg_dollar:$94.14;105% Medicare Outpatient Cost to Charge Ratio of 52%","106.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$106.36;102% of Medicaid interim rate","135.78","75","","","Percent of Total Billed Charges","neg_dollar:$135.78","155.69","86","","","Percent of Total Billed Charges","neg_dollar:$155.69","126.72","70","","","Percent of Total Billed Charges","neg_dollar:$126.72","103.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$103.19;103.5% of Medicaid interim rate","181.04","150","","","Percent of Total Billed Charges","neg_dollar:$279.89;150% of Medicaid interim rate","144.83","80","","","Percent of Total Billed Charges","neg_dollar:$144.83;Percent of Total Billed Charges","166.55","92","","","Percent of Total Billed Charges","neg_dollar:$166.55","94.14","52","","","Percent of Total Billed Charges","neg_dollar:$94.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.14","52","","","Percent of Total Billed Charges","neg_dollar:$94.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.00","181.00",""
"PRIVIGEN 5 GM/50ML IV SOLN","J1459","HCPCS","44206-438-92","NDC","636","RC","","Facility","Outpatient","1","UN","183.22","183.22","","","","183.22","Fee Schedule","","","","","183.22","Fee Schedule","101% of Medicare Fee Schedule","","","","183.22","Fee Schedule","","95.27","52","","","Percent of Total Billed Charges","neg_dollar:$95.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","183.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","183.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","157.57","86","","","Percent of Total Billed Charges","neg_dollar:$157.57","128.25","70","","","Percent of Total Billed Charges","neg_dollar:$128.25","95.27","52","","","Percent of Total Billed Charges","neg_dollar:$95.27;105% Medicare Outpatient Cost to Charge Ratio of 52%","107.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$107.64;102% of Medicaid interim rate","137.42","75","","","Percent of Total Billed Charges","neg_dollar:$137.42","157.57","86","","","Percent of Total Billed Charges","neg_dollar:$157.57","128.25","70","","","Percent of Total Billed Charges","neg_dollar:$128.25","104.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$104.43;103.5% of Medicaid interim rate","183.22","150","","","Percent of Total Billed Charges","neg_dollar:$283.27;150% of Medicaid interim rate","146.58","80","","","Percent of Total Billed Charges","neg_dollar:$146.58;Percent of Total Billed Charges","168.56","92","","","Percent of Total Billed Charges","neg_dollar:$168.56","95.27","52","","","Percent of Total Billed Charges","neg_dollar:$95.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","95.27","52","","","Percent of Total Billed Charges","neg_dollar:$95.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","95.00","183.00",""
"PRIVIGEN 5 GM/50ML IV SOLN","J1459","HCPCS","44206-436-90","NDC","636","RC","","Facility","Outpatient","1","UN","188.28","188.28","","","","188.28","Fee Schedule","","","","","188.28","Fee Schedule","101% of Medicare Fee Schedule","","","","188.28","Fee Schedule","","97.90","52","","","Percent of Total Billed Charges","neg_dollar:$97.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","188.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","188.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","161.92","86","","","Percent of Total Billed Charges","neg_dollar:$161.92","131.79","70","","","Percent of Total Billed Charges","neg_dollar:$131.79","97.90","52","","","Percent of Total Billed Charges","neg_dollar:$97.90;105% Medicare Outpatient Cost to Charge Ratio of 52%","110.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$110.61;102% of Medicaid interim rate","141.21","75","","","Percent of Total Billed Charges","neg_dollar:$141.21","161.92","86","","","Percent of Total Billed Charges","neg_dollar:$161.92","131.79","70","","","Percent of Total Billed Charges","neg_dollar:$131.79","107.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$107.31;103.5% of Medicaid interim rate","188.28","150","","","Percent of Total Billed Charges","neg_dollar:$291.09;150% of Medicaid interim rate","150.62","80","","","Percent of Total Billed Charges","neg_dollar:$150.62;Percent of Total Billed Charges","173.21","92","","","Percent of Total Billed Charges","neg_dollar:$173.21","97.90","52","","","Percent of Total Billed Charges","neg_dollar:$97.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","97.90","52","","","Percent of Total Billed Charges","neg_dollar:$97.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","97.00","188.00",""
"PRIVIGEN 5 GM/50ML IV SOLN","J1459","HCPCS","44206-439-93","NDC","636","RC","","Facility","Outpatient","1","UN","189.37","189.37","","","","189.37","Fee Schedule","","","","","189.37","Fee Schedule","101% of Medicare Fee Schedule","","","","189.37","Fee Schedule","","98.47","52","","","Percent of Total Billed Charges","neg_dollar:$98.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","189.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","189.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","162.86","86","","","Percent of Total Billed Charges","neg_dollar:$162.86","132.56","70","","","Percent of Total Billed Charges","neg_dollar:$132.56","98.47","52","","","Percent of Total Billed Charges","neg_dollar:$98.47;105% Medicare Outpatient Cost to Charge Ratio of 52%","111.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$111.25;102% of Medicaid interim rate","142.03","75","","","Percent of Total Billed Charges","neg_dollar:$142.03","162.86","86","","","Percent of Total Billed Charges","neg_dollar:$162.86","132.56","70","","","Percent of Total Billed Charges","neg_dollar:$132.56","107.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$107.94;103.5% of Medicaid interim rate","189.37","150","","","Percent of Total Billed Charges","neg_dollar:$292.78;150% of Medicaid interim rate","151.49","80","","","Percent of Total Billed Charges","neg_dollar:$151.49;Percent of Total Billed Charges","174.22","92","","","Percent of Total Billed Charges","neg_dollar:$174.22","98.47","52","","","Percent of Total Billed Charges","neg_dollar:$98.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","98.47","52","","","Percent of Total Billed Charges","neg_dollar:$98.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","98.00","189.00",""
"PRIVIGEN 5 GM/50ML IV SOLN","J1459","HCPCS","44206-436-05","NDC","636","RC","","Facility","Outpatient","1","UN","185.78","185.78","","","","185.78","Fee Schedule","","","","","185.78","Fee Schedule","101% of Medicare Fee Schedule","","","","185.78","Fee Schedule","","96.60","52","","","Percent of Total Billed Charges","neg_dollar:$96.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","185.78","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","185.78","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","159.77","86","","","Percent of Total Billed Charges","neg_dollar:$159.77","130.05","70","","","Percent of Total Billed Charges","neg_dollar:$130.05","96.60","52","","","Percent of Total Billed Charges","neg_dollar:$96.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","109.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$109.14;102% of Medicaid interim rate","139.33","75","","","Percent of Total Billed Charges","neg_dollar:$139.33","159.77","86","","","Percent of Total Billed Charges","neg_dollar:$159.77","130.05","70","","","Percent of Total Billed Charges","neg_dollar:$130.05","105.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$105.89;103.5% of Medicaid interim rate","185.78","150","","","Percent of Total Billed Charges","neg_dollar:$287.23;150% of Medicaid interim rate","148.62","80","","","Percent of Total Billed Charges","neg_dollar:$148.62;Percent of Total Billed Charges","170.92","92","","","Percent of Total Billed Charges","neg_dollar:$170.92","96.60","52","","","Percent of Total Billed Charges","neg_dollar:$96.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","96.60","52","","","Percent of Total Billed Charges","neg_dollar:$96.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","96.00","185.00",""
"PRIVIGEN 5 GM/50ML IV SOLN","J1459","HCPCS","44206-439-40","NDC","636","RC","","Facility","Outpatient","1","UN","186.66","186.66","","","","186.66","Fee Schedule","","","","","186.66","Fee Schedule","101% of Medicare Fee Schedule","","","","186.66","Fee Schedule","","97.06","52","","","Percent of Total Billed Charges","neg_dollar:$97.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","186.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","186.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","160.53","86","","","Percent of Total Billed Charges","neg_dollar:$160.53","130.66","70","","","Percent of Total Billed Charges","neg_dollar:$130.66","97.06","52","","","Percent of Total Billed Charges","neg_dollar:$97.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","109.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$109.66;102% of Medicaid interim rate","139.99","75","","","Percent of Total Billed Charges","neg_dollar:$139.99","160.53","86","","","Percent of Total Billed Charges","neg_dollar:$160.53","130.66","70","","","Percent of Total Billed Charges","neg_dollar:$130.66","106.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$106.39;103.5% of Medicaid interim rate","186.66","150","","","Percent of Total Billed Charges","neg_dollar:$288.59;150% of Medicaid interim rate","149.33","80","","","Percent of Total Billed Charges","neg_dollar:$149.33;Percent of Total Billed Charges","171.73","92","","","Percent of Total Billed Charges","neg_dollar:$171.73","97.06","52","","","Percent of Total Billed Charges","neg_dollar:$97.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","97.06","52","","","Percent of Total Billed Charges","neg_dollar:$97.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","97.00","186.00",""
"PRIVIGEN 5 GM/50ML IV SOLN","J1459","HCPCS","44206-439-93","NDC","636","RC","","Facility","Outpatient","1","UN","182.01","182.01","","","","182.01","Fee Schedule","","","","","182.01","Fee Schedule","101% of Medicare Fee Schedule","","","","182.01","Fee Schedule","","94.64","52","","","Percent of Total Billed Charges","neg_dollar:$94.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","182.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","156.53","86","","","Percent of Total Billed Charges","neg_dollar:$156.53","127.40","70","","","Percent of Total Billed Charges","neg_dollar:$127.40","94.64","52","","","Percent of Total Billed Charges","neg_dollar:$94.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","106.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$106.93;102% of Medicaid interim rate","136.50","75","","","Percent of Total Billed Charges","neg_dollar:$136.50","156.53","86","","","Percent of Total Billed Charges","neg_dollar:$156.53","127.40","70","","","Percent of Total Billed Charges","neg_dollar:$127.40","103.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$103.74;103.5% of Medicaid interim rate","182.01","150","","","Percent of Total Billed Charges","neg_dollar:$281.39;150% of Medicaid interim rate","145.60","80","","","Percent of Total Billed Charges","neg_dollar:$145.60;Percent of Total Billed Charges","167.45","92","","","Percent of Total Billed Charges","neg_dollar:$167.45","94.64","52","","","Percent of Total Billed Charges","neg_dollar:$94.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.64","52","","","Percent of Total Billed Charges","neg_dollar:$94.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","94.00","182.00",""
"GAMUNEX-C 10 GM/100ML IJ SOLN","J1561","HCPCS","13533-800-71","NDC","636","RC","","Facility","Outpatient","1","UN","149.83","149.83","","","","149.83","Fee Schedule","","","","","149.83","Fee Schedule","101% of Medicare Fee Schedule","","","","149.83","Fee Schedule","","77.91","52","","","Percent of Total Billed Charges","neg_dollar:$77.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","149.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","149.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","128.85","86","","","Percent of Total Billed Charges","neg_dollar:$128.85","104.88","70","","","Percent of Total Billed Charges","neg_dollar:$104.88","77.91","52","","","Percent of Total Billed Charges","neg_dollar:$77.91;105% Medicare Outpatient Cost to Charge Ratio of 52%","88.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$88.02;102% of Medicaid interim rate","112.37","75","","","Percent of Total Billed Charges","neg_dollar:$112.37","128.85","86","","","Percent of Total Billed Charges","neg_dollar:$128.85","104.88","70","","","Percent of Total Billed Charges","neg_dollar:$104.88","85.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$85.40;103.5% of Medicaid interim rate","149.83","150","","","Percent of Total Billed Charges","neg_dollar:$231.64;150% of Medicaid interim rate","119.86","80","","","Percent of Total Billed Charges","neg_dollar:$119.86;Percent of Total Billed Charges","137.84","92","","","Percent of Total Billed Charges","neg_dollar:$137.84","77.91","52","","","Percent of Total Billed Charges","neg_dollar:$77.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","77.91","52","","","Percent of Total Billed Charges","neg_dollar:$77.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","77.00","149.00",""
"GAMUNEX-C 20 GM/200ML IJ SOLN","J1561","HCPCS","13533-800-25","NDC","636","RC","","Facility","Outpatient","1","UN","147.45","147.45","","","","147.45","Fee Schedule","","","","","147.45","Fee Schedule","101% of Medicare Fee Schedule","","","","147.45","Fee Schedule","","76.67","52","","","Percent of Total Billed Charges","neg_dollar:$76.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","147.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","147.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","126.81","86","","","Percent of Total Billed Charges","neg_dollar:$126.81","103.22","70","","","Percent of Total Billed Charges","neg_dollar:$103.22","76.67","52","","","Percent of Total Billed Charges","neg_dollar:$76.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","86.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$86.63;102% of Medicaid interim rate","110.59","75","","","Percent of Total Billed Charges","neg_dollar:$110.59","126.81","86","","","Percent of Total Billed Charges","neg_dollar:$126.81","103.22","70","","","Percent of Total Billed Charges","neg_dollar:$103.22","84.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$84.05;103.5% of Medicaid interim rate","147.45","150","","","Percent of Total Billed Charges","neg_dollar:$227.97;150% of Medicaid interim rate","117.96","80","","","Percent of Total Billed Charges","neg_dollar:$117.96;Percent of Total Billed Charges","135.66","92","","","Percent of Total Billed Charges","neg_dollar:$135.66","76.67","52","","","Percent of Total Billed Charges","neg_dollar:$76.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","76.67","52","","","Percent of Total Billed Charges","neg_dollar:$76.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","76.00","147.00",""
"GAMUNEX-C 20 GM/200ML IJ SOLN","J1561","HCPCS","13533-800-24","NDC","636","RC","","Facility","Outpatient","1","UN","147.64","147.64","","","","147.64","Fee Schedule","","","","","147.64","Fee Schedule","101% of Medicare Fee Schedule","","","","147.64","Fee Schedule","","76.77","52","","","Percent of Total Billed Charges","neg_dollar:$76.77;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","147.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","147.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","126.97","86","","","Percent of Total Billed Charges","neg_dollar:$126.97","103.34","70","","","Percent of Total Billed Charges","neg_dollar:$103.34","76.77","52","","","Percent of Total Billed Charges","neg_dollar:$76.77;105% Medicare Outpatient Cost to Charge Ratio of 52%","86.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$86.73;102% of Medicaid interim rate","110.73","75","","","Percent of Total Billed Charges","neg_dollar:$110.73","126.97","86","","","Percent of Total Billed Charges","neg_dollar:$126.97","103.34","70","","","Percent of Total Billed Charges","neg_dollar:$103.34","84.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$84.15;103.5% of Medicaid interim rate","147.64","150","","","Percent of Total Billed Charges","neg_dollar:$228.26;150% of Medicaid interim rate","118.11","80","","","Percent of Total Billed Charges","neg_dollar:$118.11;Percent of Total Billed Charges","135.83","92","","","Percent of Total Billed Charges","neg_dollar:$135.83","76.77","52","","","Percent of Total Billed Charges","neg_dollar:$76.77;100% Medicare Outpatient Cost to Charge Ratio of 52%","76.77","52","","","Percent of Total Billed Charges","neg_dollar:$76.77;100% Medicare Outpatient Cost to Charge Ratio of 52%","76.00","147.00",""
"GAMUNEX-C 20 GM/200ML IJ SOLN","J1561","HCPCS","13533-800-25","NDC","636","RC","","Facility","Outpatient","1","UN","73","73.00","","","","73.00","Fee Schedule","","","","","73.00","Fee Schedule","101% of Medicare Fee Schedule","","","","73.00","Fee Schedule","","37.96","52","","","Percent of Total Billed Charges","neg_dollar:$37.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","73.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","73.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","62.78","86","","","Percent of Total Billed Charges","neg_dollar:$62.78","51.09","70","","","Percent of Total Billed Charges","neg_dollar:$51.09","37.96","52","","","Percent of Total Billed Charges","neg_dollar:$37.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","42.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$42.88;102% of Medicaid interim rate","54.75","75","","","Percent of Total Billed Charges","neg_dollar:$54.75","62.78","86","","","Percent of Total Billed Charges","neg_dollar:$62.78","51.09","70","","","Percent of Total Billed Charges","neg_dollar:$51.09","41.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$41.61;103.5% of Medicaid interim rate","73.00","150","","","Percent of Total Billed Charges","neg_dollar:$112.86;150% of Medicaid interim rate","58.40","80","","","Percent of Total Billed Charges","neg_dollar:$58.40;Percent of Total Billed Charges","67.16","92","","","Percent of Total Billed Charges","neg_dollar:$67.16","37.96","52","","","Percent of Total Billed Charges","neg_dollar:$37.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","37.96","52","","","Percent of Total Billed Charges","neg_dollar:$37.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","37.00","73.00",""
"IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IV SOLN","J1568","HCPCS","68982-850-03","NDC","636","RC","","Facility","Outpatient","10","GM","198.62","198.62","","","","198.62","Fee Schedule","","","","","198.62","Fee Schedule","101% of Medicare Fee Schedule","","","","198.62","Fee Schedule","","103.28","52","","","Percent of Total Billed Charges","neg_dollar:$103.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","198.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","198.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","170.81","86","","","Percent of Total Billed Charges","neg_dollar:$170.81","139.03","70","","","Percent of Total Billed Charges","neg_dollar:$139.03","103.28","52","","","Percent of Total Billed Charges","neg_dollar:$103.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","116.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$116.69;102% of Medicaid interim rate","148.96","75","","","Percent of Total Billed Charges","neg_dollar:$148.96","170.81","86","","","Percent of Total Billed Charges","neg_dollar:$170.81","139.03","70","","","Percent of Total Billed Charges","neg_dollar:$139.03","113.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$113.21;103.5% of Medicaid interim rate","198.62","150","","","Percent of Total Billed Charges","neg_dollar:$307.08;150% of Medicaid interim rate","158.90","80","","","Percent of Total Billed Charges","neg_dollar:$158.90;Percent of Total Billed Charges","182.73","92","","","Percent of Total Billed Charges","neg_dollar:$182.73","103.28","52","","","Percent of Total Billed Charges","neg_dollar:$103.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","103.28","52","","","Percent of Total Billed Charges","neg_dollar:$103.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","103.00","198.00",""
"IMMUNE GLOBULIN (HUMAN) 30 GM/300ML IV SOLN","J1568","HCPCS","68982-850-05","NDC","636","RC","","Facility","Outpatient","30","GM","11684.16","11684.16","","","","11684.16","Fee Schedule","","","","","11684.16","Fee Schedule","101% of Medicare Fee Schedule","","","","11684.16","Fee Schedule","","6075.76","52","","","Percent of Total Billed Charges","neg_dollar:$6075.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11684.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11684.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10048.38","86","","","Percent of Total Billed Charges","neg_dollar:$10048.38","8178.91","70","","","Percent of Total Billed Charges","neg_dollar:$8178.91","6075.76","52","","","Percent of Total Billed Charges","neg_dollar:$6075.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","6864.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$6864.43;102% of Medicaid interim rate","8763.12","75","","","Percent of Total Billed Charges","neg_dollar:$8763.12","10048.38","86","","","Percent of Total Billed Charges","neg_dollar:$10048.38","8178.91","70","","","Percent of Total Billed Charges","neg_dollar:$8178.91","6659.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$6659.97;103.5% of Medicaid interim rate","11684.16","150","","","Percent of Total Billed Charges","neg_dollar:$18064.30;150% of Medicaid interim rate","9347.33","80","","","Percent of Total Billed Charges","neg_dollar:$9347.33;Percent of Total Billed Charges","10749.43","92","","","Percent of Total Billed Charges","neg_dollar:$10749.43","6075.76","52","","","Percent of Total Billed Charges","neg_dollar:$6075.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","6075.76","52","","","Percent of Total Billed Charges","neg_dollar:$6075.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","6075.00","11684.00",""
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","J1596","HCPCS","00143-9682-25","NDC","636","RC","","Facility","Outpatient","1","ML","44.60","44.60","","","","34.00","Fee Schedule","","","","","44.60","Fee Schedule","101% of Medicare Fee Schedule","","","","36.00","Fee Schedule","","23.19","52","","","Percent of Total Billed Charges","neg_dollar:$23.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","44.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","44.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","38.35","86","","","Percent of Total Billed Charges","neg_dollar:$38.35","31.22","70","","","Percent of Total Billed Charges","neg_dollar:$31.22","23.19","52","","","Percent of Total Billed Charges","neg_dollar:$23.19;105% Medicare Outpatient Cost to Charge Ratio of 52%","26.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.20;102% of Medicaid interim rate","33.45","75","","","Percent of Total Billed Charges","neg_dollar:$33.45","38.35","86","","","Percent of Total Billed Charges","neg_dollar:$38.35","31.22","70","","","Percent of Total Billed Charges","neg_dollar:$31.22","25.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.42;103.5% of Medicaid interim rate","44.60","150","","","Percent of Total Billed Charges","neg_dollar:$68.95;150% of Medicaid interim rate","35.68","80","","","Percent of Total Billed Charges","neg_dollar:$35.68;Percent of Total Billed Charges","41.03","92","","","Percent of Total Billed Charges","neg_dollar:$41.03","23.19","52","","","Percent of Total Billed Charges","neg_dollar:$23.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.19","52","","","Percent of Total Billed Charges","neg_dollar:$23.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.00","44.00",""
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","J1596","HCPCS","00143-9682-25","NDC","636","RC","","Facility","Outpatient","1","ML","46.35","46.35","","","","34.00","Fee Schedule","","","","","46.35","Fee Schedule","101% of Medicare Fee Schedule","","","","36.00","Fee Schedule","","24.10","52","","","Percent of Total Billed Charges","neg_dollar:$24.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","46.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","46.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","39.86","86","","","Percent of Total Billed Charges","neg_dollar:$39.86","32.44","70","","","Percent of Total Billed Charges","neg_dollar:$32.44","24.10","52","","","Percent of Total Billed Charges","neg_dollar:$24.10;105% Medicare Outpatient Cost to Charge Ratio of 52%","27.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.23;102% of Medicaid interim rate","34.76","75","","","Percent of Total Billed Charges","neg_dollar:$34.76","39.86","86","","","Percent of Total Billed Charges","neg_dollar:$39.86","32.44","70","","","Percent of Total Billed Charges","neg_dollar:$32.44","26.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.41;103.5% of Medicaid interim rate","46.35","150","","","Percent of Total Billed Charges","neg_dollar:$71.65;150% of Medicaid interim rate","37.08","80","","","Percent of Total Billed Charges","neg_dollar:$37.08;Percent of Total Billed Charges","42.64","92","","","Percent of Total Billed Charges","neg_dollar:$42.64","24.10","52","","","Percent of Total Billed Charges","neg_dollar:$24.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","24.10","52","","","Percent of Total Billed Charges","neg_dollar:$24.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","24.00","46.00",""
"GLYCOPYRROLATE 0.2 MG/ML IJ SOLN","J1596","HCPCS","00143-9682-01","NDC","250","RC","","Facility","Outpatient","1","ML","24.47","24.47","","","","24.47","Fee Schedule","","","","","24.47","Fee Schedule","","","","","24.47","Fee Schedule","","","52","","24.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.72","52","","","Percent of Total Billed Charges","neg_dollar:$12.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.72","52","","","Percent of Total Billed Charges","neg_dollar:$12.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.04","86","","","Percent of Total Billed Charges","neg_dollar:$21.04","17.13","70","","","Percent of Total Billed Charges","neg_dollar:$17.13","","52","","24.47","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.37;102% of Medicaid interim rate","18.35","75","","","Percent of Total Billed Charges","neg_dollar:$18.35","21.04","86","","","Percent of Total Billed Charges","neg_dollar:$21.04","17.13","70","","","Percent of Total Billed Charges","neg_dollar:$17.13","13.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.95;103.5% of Medicaid interim rate","24.47","150","","","Percent of Total Billed Charges","neg_dollar:$37.83;150% of Medicaid interim rate","19.58","80","","","Percent of Total Billed Charges","neg_dollar:$19.58;Percent of Total Billed Charges","22.51","92","","","Percent of Total Billed Charges","neg_dollar:$22.51","12.72","52","","","Percent of Total Billed Charges","neg_dollar:$12.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","24.47","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","24.00",""
"GLUCAGON (RDNA) 1 MG IJ KIT","J1610","HCPCS","00548-5850-00","NDC","250","RC","","Facility","Outpatient","1","ME","647.50","647.50","","","","647.50","Fee Schedule","","","","","647.50","Fee Schedule","","","","","647.50","Fee Schedule","","","52","","647.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","336.70","52","","","Percent of Total Billed Charges","neg_dollar:$336.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","336.70","52","","","Percent of Total Billed Charges","neg_dollar:$336.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","556.85","86","","","Percent of Total Billed Charges","neg_dollar:$556.85","453.24","70","","","Percent of Total Billed Charges","neg_dollar:$453.24","","52","","647.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","380.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$380.40;102% of Medicaid interim rate","485.62","75","","","Percent of Total Billed Charges","neg_dollar:$485.62","556.85","86","","","Percent of Total Billed Charges","neg_dollar:$556.85","453.24","70","","","Percent of Total Billed Charges","neg_dollar:$453.24","369.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$369.07;103.5% of Medicaid interim rate","647.50","150","","","Percent of Total Billed Charges","neg_dollar:$1001.06;150% of Medicaid interim rate","518.00","80","","","Percent of Total Billed Charges","neg_dollar:$518;Percent of Total Billed Charges","595.70","92","","","Percent of Total Billed Charges","neg_dollar:$595.70","336.70","52","","","Percent of Total Billed Charges","neg_dollar:$336.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","647.50","Fee Schedule","","336.00","647.00",""
"GLUCAGON (RDNA) 1 MG IJ KIT","J1610","HCPCS","00548-5850-00","NDC","636","RC","","Facility","Outpatient","1","ME","647.50","647.50","","","","647.50","Fee Schedule","","","","","647.50","Fee Schedule","101% of Medicare Fee Schedule","","","","647.50","Fee Schedule","","336.70","52","","","Percent of Total Billed Charges","neg_dollar:$336.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","647.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","647.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","556.85","86","","","Percent of Total Billed Charges","neg_dollar:$556.85","453.24","70","","","Percent of Total Billed Charges","neg_dollar:$453.24","336.70","52","","","Percent of Total Billed Charges","neg_dollar:$336.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","380.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$380.40;102% of Medicaid interim rate","485.62","75","","","Percent of Total Billed Charges","neg_dollar:$485.62","556.85","86","","","Percent of Total Billed Charges","neg_dollar:$556.85","453.24","70","","","Percent of Total Billed Charges","neg_dollar:$453.24","369.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$369.07;103.5% of Medicaid interim rate","647.50","150","","","Percent of Total Billed Charges","neg_dollar:$1001.06;150% of Medicaid interim rate","518.00","80","","","Percent of Total Billed Charges","neg_dollar:$518;Percent of Total Billed Charges","595.70","92","","","Percent of Total Billed Charges","neg_dollar:$595.70","336.70","52","","","Percent of Total Billed Charges","neg_dollar:$336.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","336.70","52","","","Percent of Total Billed Charges","neg_dollar:$336.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","336.00","647.00",""
"HALOPERIDOL LACTATE 5 MG/ML IJ SOLN","J1630","HCPCS","67457-426-12","NDC","636","RC","","Facility","Outpatient","1","ML","88.81","88.81","","","","33.00","Fee Schedule","","","","","45.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.18","52","","","Percent of Total Billed Charges","neg_dollar:$46.18;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.38","86","","","Percent of Total Billed Charges","neg_dollar:$76.38","62.17","70","","","Percent of Total Billed Charges","neg_dollar:$62.17","46.18","52","","","Percent of Total Billed Charges","neg_dollar:$46.18;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.18;102% of Medicaid interim rate","66.61","75","","","Percent of Total Billed Charges","neg_dollar:$66.61","76.38","86","","","Percent of Total Billed Charges","neg_dollar:$76.38","62.17","70","","","Percent of Total Billed Charges","neg_dollar:$62.17","50.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.62;103.5% of Medicaid interim rate","88.81","150","","","Percent of Total Billed Charges","neg_dollar:$137.31;150% of Medicaid interim rate","71.05","80","","","Percent of Total Billed Charges","neg_dollar:$71.05;Percent of Total Billed Charges","81.71","92","","","Percent of Total Billed Charges","neg_dollar:$81.71","46.18","52","","","Percent of Total Billed Charges","neg_dollar:$46.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.18","52","","","Percent of Total Billed Charges","neg_dollar:$46.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"HALOPERIDOL LACTATE 5 MG/ML IJ SOLN","J1630","HCPCS","67457-426-12","NDC","250","RC","","Facility","Outpatient","1","ML","89.30","89.30","","","","33.00","Fee Schedule","","","","","45.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","89.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.79","86","","","Percent of Total Billed Charges","neg_dollar:$76.79","62.50","70","","","Percent of Total Billed Charges","neg_dollar:$62.50","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.46;102% of Medicaid interim rate","66.97","75","","","Percent of Total Billed Charges","neg_dollar:$66.97","76.79","86","","","Percent of Total Billed Charges","neg_dollar:$76.79","62.50","70","","","Percent of Total Billed Charges","neg_dollar:$62.50","50.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.90;103.5% of Medicaid interim rate","89.30","150","","","Percent of Total Billed Charges","neg_dollar:$138.06;150% of Medicaid interim rate","71.44","80","","","Percent of Total Billed Charges","neg_dollar:$71.44;Percent of Total Billed Charges","82.15","92","","","Percent of Total Billed Charges","neg_dollar:$82.15","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","89.00",""
"HEPARIN NA (PORK) LOCK FLSH PF 100 UNIT/ML IV SOLN","J1642","HCPCS","64253-333-35","NDC","636","RC","","Facility","Outpatient","1","ML","1.78","1.78","","","","1.78","Fee Schedule","","","","","1.78","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","0.92","52","","","Percent of Total Billed Charges","neg_dollar:$0.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.78","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.78","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.53","86","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.24","70","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.92","52","","","Percent of Total Billed Charges","neg_dollar:$0.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% of Medicaid interim rate","1.33","75","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.53","86","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.24","70","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.01;103.5% of Medicaid interim rate","1.78","150","","","Percent of Total Billed Charges","neg_dollar:$2.75;150% of Medicaid interim rate","1.42","80","","","Percent of Total Billed Charges","neg_dollar:$1.42;Percent of Total Billed Charges","1.64","92","","","Percent of Total Billed Charges","neg_dollar:$1.64","0.92","52","","","Percent of Total Billed Charges","neg_dollar:$0.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.92","52","","","Percent of Total Billed Charges","neg_dollar:$0.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HEPARIN NA (PORK) LOCK FLSH PF 100 UNIT/ML IV SOLN","J1642","HCPCS","8290-306424","NDC","636","RC","","Facility","Outpatient","1","ML","1.77","1.77","","","","1.77","Fee Schedule","","","","","1.77","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","0.92","52","","","Percent of Total Billed Charges","neg_dollar:$0.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.52","86","","","Percent of Total Billed Charges","neg_dollar:$1.52","1.24","70","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.92","52","","","Percent of Total Billed Charges","neg_dollar:$0.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% of Medicaid interim rate","1.33","75","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.52","86","","","Percent of Total Billed Charges","neg_dollar:$1.52","1.24","70","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.01;103.5% of Medicaid interim rate","1.77","150","","","Percent of Total Billed Charges","neg_dollar:$2.74;150% of Medicaid interim rate","1.42","80","","","Percent of Total Billed Charges","neg_dollar:$1.42;Percent of Total Billed Charges","1.63","92","","","Percent of Total Billed Charges","neg_dollar:$1.63","0.92","52","","","Percent of Total Billed Charges","neg_dollar:$0.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.92","52","","","Percent of Total Billed Charges","neg_dollar:$0.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","J1644","HCPCS","71288-402-01","NDC","250","RC","","Facility","Outpatient","1","ML","17.97","17.97","","","","17.97","Fee Schedule","","","","","17.97","Fee Schedule","","","","","17.97","Fee Schedule","","","52","","17.97","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.34","52","","","Percent of Total Billed Charges","neg_dollar:$9.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.34","52","","","Percent of Total Billed Charges","neg_dollar:$9.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.45","86","","","Percent of Total Billed Charges","neg_dollar:$15.45","12.57","70","","","Percent of Total Billed Charges","neg_dollar:$12.57","","52","","17.97","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.55;102% of Medicaid interim rate","13.47","75","","","Percent of Total Billed Charges","neg_dollar:$13.47","15.45","86","","","Percent of Total Billed Charges","neg_dollar:$15.45","12.57","70","","","Percent of Total Billed Charges","neg_dollar:$12.57","10.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.24;103.5% of Medicaid interim rate","17.97","150","","","Percent of Total Billed Charges","neg_dollar:$27.78;150% of Medicaid interim rate","14.37","80","","","Percent of Total Billed Charges","neg_dollar:$14.37;Percent of Total Billed Charges","16.53","92","","","Percent of Total Billed Charges","neg_dollar:$16.53","9.34","52","","","Percent of Total Billed Charges","neg_dollar:$9.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","17.97","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","17.00",""
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN","J1644","HCPCS","71288-402-01","NDC","636","RC","","Facility","Outpatient","1","ML","21.09","21.09","","","","21.09","Fee Schedule","","","","","21.09","Fee Schedule","101% of Medicare Fee Schedule","","","","21.09","Fee Schedule","","10.96","52","","","Percent of Total Billed Charges","neg_dollar:$10.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","21.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","21.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","18.14","86","","","Percent of Total Billed Charges","neg_dollar:$18.14","14.76","70","","","Percent of Total Billed Charges","neg_dollar:$14.76","10.96","52","","","Percent of Total Billed Charges","neg_dollar:$10.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","12.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.39;102% of Medicaid interim rate","15.82","75","","","Percent of Total Billed Charges","neg_dollar:$15.82","18.14","86","","","Percent of Total Billed Charges","neg_dollar:$18.14","14.76","70","","","Percent of Total Billed Charges","neg_dollar:$14.76","12.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.02;103.5% of Medicaid interim rate","21.09","150","","","Percent of Total Billed Charges","neg_dollar:$32.61;150% of Medicaid interim rate","16.87","80","","","Percent of Total Billed Charges","neg_dollar:$16.87;Percent of Total Billed Charges","19.40","92","","","Percent of Total Billed Charges","neg_dollar:$19.40","10.96","52","","","Percent of Total Billed Charges","neg_dollar:$10.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.96","52","","","Percent of Total Billed Charges","neg_dollar:$10.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.00","21.00",""
"HEPARIN (PORCINE) IN NACL 25000-0.45 UT/500ML-% IV SOLN","J1644","HCPCS","63323-518-77","NDC","636","RC","","Facility","Outpatient","1","UN","4.06","4.06","","","","4.06","Fee Schedule","","","","","4.06","Fee Schedule","101% of Medicare Fee Schedule","","","","4.06","Fee Schedule","","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.49","86","","","Percent of Total Billed Charges","neg_dollar:$3.49","2.84","70","","","Percent of Total Billed Charges","neg_dollar:$2.84","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.38;102% of Medicaid interim rate","3.04","75","","","Percent of Total Billed Charges","neg_dollar:$3.04","3.49","86","","","Percent of Total Billed Charges","neg_dollar:$3.49","2.84","70","","","Percent of Total Billed Charges","neg_dollar:$2.84","2.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.31;103.5% of Medicaid interim rate","4.06","150","","","Percent of Total Billed Charges","neg_dollar:$6.27;150% of Medicaid interim rate","3.24","80","","","Percent of Total Billed Charges","neg_dollar:$3.24;Percent of Total Billed Charges","3.73","92","","","Percent of Total Billed Charges","neg_dollar:$3.73","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"HEPARIN PREMIX 50 UNITS/ML","J1644","HCPCS","63323-518-77","NDC","636","RC","","Facility","Outpatient","1","ML","4.06","4.06","","","","4.06","Fee Schedule","","","","","4.06","Fee Schedule","101% of Medicare Fee Schedule","","","","4.06","Fee Schedule","","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.49","86","","","Percent of Total Billed Charges","neg_dollar:$3.49","2.84","70","","","Percent of Total Billed Charges","neg_dollar:$2.84","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.38;102% of Medicaid interim rate","3.04","75","","","Percent of Total Billed Charges","neg_dollar:$3.04","3.49","86","","","Percent of Total Billed Charges","neg_dollar:$3.49","2.84","70","","","Percent of Total Billed Charges","neg_dollar:$2.84","2.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.31;103.5% of Medicaid interim rate","4.06","150","","","Percent of Total Billed Charges","neg_dollar:$6.27;150% of Medicaid interim rate","3.24","80","","","Percent of Total Billed Charges","neg_dollar:$3.24;Percent of Total Billed Charges","3.73","92","","","Percent of Total Billed Charges","neg_dollar:$3.73","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"HEPARIN PREMIX 50 UNITS/ML","J1644","HCPCS","63323-518-77","NDC","250","RC","","Facility","Outpatient","1","ML","4.06","4.06","","","","4.06","Fee Schedule","","","","","4.06","Fee Schedule","","","","","4.06","Fee Schedule","","","52","","4.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.49","86","","","Percent of Total Billed Charges","neg_dollar:$3.49","2.84","70","","","Percent of Total Billed Charges","neg_dollar:$2.84","","52","","4.06","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.38;102% of Medicaid interim rate","3.04","75","","","Percent of Total Billed Charges","neg_dollar:$3.04","3.49","86","","","Percent of Total Billed Charges","neg_dollar:$3.49","2.84","70","","","Percent of Total Billed Charges","neg_dollar:$2.84","2.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.31;103.5% of Medicaid interim rate","4.06","150","","","Percent of Total Billed Charges","neg_dollar:$6.27;150% of Medicaid interim rate","3.24","80","","","Percent of Total Billed Charges","neg_dollar:$3.24;Percent of Total Billed Charges","3.73","92","","","Percent of Total Billed Charges","neg_dollar:$3.73","2.11","52","","","Percent of Total Billed Charges","neg_dollar:$2.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.06","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","J1644","HCPCS","63323-262-06","NDC","250","RC","","Facility","Outpatient","1","ML","12.87","12.87","","","","12.87","Fee Schedule","","","","","12.87","Fee Schedule","","","","","12.87","Fee Schedule","","","52","","12.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.69","52","","","Percent of Total Billed Charges","neg_dollar:$6.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.69","52","","","Percent of Total Billed Charges","neg_dollar:$6.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.07","86","","","Percent of Total Billed Charges","neg_dollar:$11.07","9.01","70","","","Percent of Total Billed Charges","neg_dollar:$9.01","","52","","12.87","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.56;102% of Medicaid interim rate","9.65","75","","","Percent of Total Billed Charges","neg_dollar:$9.65","11.07","86","","","Percent of Total Billed Charges","neg_dollar:$11.07","9.01","70","","","Percent of Total Billed Charges","neg_dollar:$9.01","7.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.33;103.5% of Medicaid interim rate","12.87","150","","","Percent of Total Billed Charges","neg_dollar:$19.90;150% of Medicaid interim rate","10.29","80","","","Percent of Total Billed Charges","neg_dollar:$10.29;Percent of Total Billed Charges","11.84","92","","","Percent of Total Billed Charges","neg_dollar:$11.84","6.69","52","","","Percent of Total Billed Charges","neg_dollar:$6.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.87","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","12.00",""
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","J1644","HCPCS","63323-262-03","NDC","636","RC","","Facility","Outpatient","1","ML","17.88","17.88","","","","17.88","Fee Schedule","","","","","17.88","Fee Schedule","101% of Medicare Fee Schedule","","","","17.88","Fee Schedule","","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.38","86","","","Percent of Total Billed Charges","neg_dollar:$15.38","12.51","70","","","Percent of Total Billed Charges","neg_dollar:$12.51","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.50;102% of Medicaid interim rate","13.41","75","","","Percent of Total Billed Charges","neg_dollar:$13.41","15.38","86","","","Percent of Total Billed Charges","neg_dollar:$15.38","12.51","70","","","Percent of Total Billed Charges","neg_dollar:$12.51","10.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.19;103.5% of Medicaid interim rate","17.88","150","","","Percent of Total Billed Charges","neg_dollar:$27.65;150% of Medicaid interim rate","14.30","80","","","Percent of Total Billed Charges","neg_dollar:$14.30;Percent of Total Billed Charges","16.45","92","","","Percent of Total Billed Charges","neg_dollar:$16.45","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","17.00",""
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN","J1644","HCPCS","63323-262-03","NDC","250","RC","","Facility","Outpatient","1","ML","14.18","14.18","","","","14.18","Fee Schedule","","","","","14.18","Fee Schedule","","","","","14.18","Fee Schedule","","","52","","14.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.37","52","","","Percent of Total Billed Charges","neg_dollar:$7.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.37","52","","","Percent of Total Billed Charges","neg_dollar:$7.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.20","86","","","Percent of Total Billed Charges","neg_dollar:$12.20","9.93","70","","","Percent of Total Billed Charges","neg_dollar:$9.93","","52","","14.18","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.33;102% of Medicaid interim rate","10.63","75","","","Percent of Total Billed Charges","neg_dollar:$10.63","12.20","86","","","Percent of Total Billed Charges","neg_dollar:$12.20","9.93","70","","","Percent of Total Billed Charges","neg_dollar:$9.93","8.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.08;103.5% of Medicaid interim rate","14.18","150","","","Percent of Total Billed Charges","neg_dollar:$21.93;150% of Medicaid interim rate","11.34","80","","","Percent of Total Billed Charges","neg_dollar:$11.34;Percent of Total Billed Charges","13.05","92","","","Percent of Total Billed Charges","neg_dollar:$13.05","7.37","52","","","Percent of Total Billed Charges","neg_dollar:$7.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","14.18","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","14.00",""
"ENOXAPARIN SODIUM 100 MG/ML IJ SOSY","J1650","HCPCS","00955-1010-10","NDC","636","RC","","Facility","Outpatient","100","ME","13.48","13.48","","","","13.48","Fee Schedule","","","","","13.48","Fee Schedule","101% of Medicare Fee Schedule","","","","13.48","Fee Schedule","","7.01","52","","","Percent of Total Billed Charges","neg_dollar:$7.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.59","86","","","Percent of Total Billed Charges","neg_dollar:$11.59","9.44","70","","","Percent of Total Billed Charges","neg_dollar:$9.44","7.01","52","","","Percent of Total Billed Charges","neg_dollar:$7.01;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.92;102% of Medicaid interim rate","10.11","75","","","Percent of Total Billed Charges","neg_dollar:$10.11","11.59","86","","","Percent of Total Billed Charges","neg_dollar:$11.59","9.44","70","","","Percent of Total Billed Charges","neg_dollar:$9.44","7.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.68;103.5% of Medicaid interim rate","13.48","150","","","Percent of Total Billed Charges","neg_dollar:$20.85;150% of Medicaid interim rate","10.78","80","","","Percent of Total Billed Charges","neg_dollar:$10.78;Percent of Total Billed Charges","12.40","92","","","Percent of Total Billed Charges","neg_dollar:$12.40","7.01","52","","","Percent of Total Billed Charges","neg_dollar:$7.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.01","52","","","Percent of Total Billed Charges","neg_dollar:$7.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","13.00",""
"ENOXAPARIN SODIUM 100 MG/ML IJ SOSY","J1650","HCPCS","71288-436-91","NDC","250","RC","","Facility","Outpatient","100","ME","10.15","10.15","","","","10.15","Fee Schedule","","","","","10.15","Fee Schedule","","","","","10.15","Fee Schedule","","","52","","10.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.28","52","","","Percent of Total Billed Charges","neg_dollar:$5.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.28","52","","","Percent of Total Billed Charges","neg_dollar:$5.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.73","86","","","Percent of Total Billed Charges","neg_dollar:$8.73","7.10","70","","","Percent of Total Billed Charges","neg_dollar:$7.10","","52","","10.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.96;102% of Medicaid interim rate","7.61","75","","","Percent of Total Billed Charges","neg_dollar:$7.61","8.73","86","","","Percent of Total Billed Charges","neg_dollar:$8.73","7.10","70","","","Percent of Total Billed Charges","neg_dollar:$7.10","5.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.78;103.5% of Medicaid interim rate","10.15","150","","","Percent of Total Billed Charges","neg_dollar:$15.70;150% of Medicaid interim rate","8.12","80","","","Percent of Total Billed Charges","neg_dollar:$8.12;Percent of Total Billed Charges","9.34","92","","","Percent of Total Billed Charges","neg_dollar:$9.34","5.28","52","","","Percent of Total Billed Charges","neg_dollar:$5.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.15","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"ENOXAPARIN SODIUM 100 MG/ML IJ SOSY","J1650","HCPCS","71288-436-91","NDC","636","RC","","Facility","Outpatient","100","ME","10.71","10.71","","","","10.71","Fee Schedule","","","","","10.71","Fee Schedule","101% of Medicare Fee Schedule","","","","10.71","Fee Schedule","","5.57","52","","","Percent of Total Billed Charges","neg_dollar:$5.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.21","86","","","Percent of Total Billed Charges","neg_dollar:$9.21","7.49","70","","","Percent of Total Billed Charges","neg_dollar:$7.49","5.57","52","","","Percent of Total Billed Charges","neg_dollar:$5.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.29;102% of Medicaid interim rate","8.03","75","","","Percent of Total Billed Charges","neg_dollar:$8.03","9.21","86","","","Percent of Total Billed Charges","neg_dollar:$9.21","7.49","70","","","Percent of Total Billed Charges","neg_dollar:$7.49","6.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.10;103.5% of Medicaid interim rate","10.71","150","","","Percent of Total Billed Charges","neg_dollar:$16.56;150% of Medicaid interim rate","8.57","80","","","Percent of Total Billed Charges","neg_dollar:$8.57;Percent of Total Billed Charges","9.85","92","","","Percent of Total Billed Charges","neg_dollar:$9.85","5.57","52","","","Percent of Total Billed Charges","neg_dollar:$5.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.57","52","","","Percent of Total Billed Charges","neg_dollar:$5.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY","J1650","HCPCS","71288-437-92","NDC","636","RC","","Facility","Outpatient","120","ME","9.14","9.14","","","","9.14","Fee Schedule","","","","","9.14","Fee Schedule","101% of Medicare Fee Schedule","","","","9.14","Fee Schedule","","4.75","52","","","Percent of Total Billed Charges","neg_dollar:$4.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.14","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.14","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.86","86","","","Percent of Total Billed Charges","neg_dollar:$7.86","6.39","70","","","Percent of Total Billed Charges","neg_dollar:$6.39","4.75","52","","","Percent of Total Billed Charges","neg_dollar:$4.75;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.37;102% of Medicaid interim rate","6.85","75","","","Percent of Total Billed Charges","neg_dollar:$6.85","7.86","86","","","Percent of Total Billed Charges","neg_dollar:$7.86","6.39","70","","","Percent of Total Billed Charges","neg_dollar:$6.39","5.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.21;103.5% of Medicaid interim rate","9.14","150","","","Percent of Total Billed Charges","neg_dollar:$14.13;150% of Medicaid interim rate","7.31","80","","","Percent of Total Billed Charges","neg_dollar:$7.31;Percent of Total Billed Charges","8.41","92","","","Percent of Total Billed Charges","neg_dollar:$8.41","4.75","52","","","Percent of Total Billed Charges","neg_dollar:$4.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.75","52","","","Percent of Total Billed Charges","neg_dollar:$4.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","9.00",""
"ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY","J1650","HCPCS","71288-437-92","NDC","636","RC","","Facility","Outpatient","120","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","101% of Medicare Fee Schedule","","","","1.40","Fee Schedule","","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY","J1650","HCPCS","71288-437-93","NDC","636","RC","","Facility","Outpatient","120","ME","9.29","9.29","","","","9.29","Fee Schedule","","","","","9.29","Fee Schedule","101% of Medicare Fee Schedule","","","","9.29","Fee Schedule","","4.83","52","","","Percent of Total Billed Charges","neg_dollar:$4.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.29","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.29","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.99","86","","","Percent of Total Billed Charges","neg_dollar:$7.99","6.50","70","","","Percent of Total Billed Charges","neg_dollar:$6.50","4.83","52","","","Percent of Total Billed Charges","neg_dollar:$4.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.46;102% of Medicaid interim rate","6.97","75","","","Percent of Total Billed Charges","neg_dollar:$6.97","7.99","86","","","Percent of Total Billed Charges","neg_dollar:$7.99","6.50","70","","","Percent of Total Billed Charges","neg_dollar:$6.50","5.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.29;103.5% of Medicaid interim rate","9.29","150","","","Percent of Total Billed Charges","neg_dollar:$14.37;150% of Medicaid interim rate","7.43","80","","","Percent of Total Billed Charges","neg_dollar:$7.43;Percent of Total Billed Charges","8.55","92","","","Percent of Total Billed Charges","neg_dollar:$8.55","4.83","52","","","Percent of Total Billed Charges","neg_dollar:$4.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.83","52","","","Percent of Total Billed Charges","neg_dollar:$4.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","9.00",""
"ENOXAPARIN SODIUM 150 MG/ML IJ SOSY","J1650","HCPCS","16714-066-01","NDC","636","RC","","Facility","Outpatient","150","ME","9.82","9.82","","","","9.82","Fee Schedule","","","","","9.82","Fee Schedule","101% of Medicare Fee Schedule","","","","9.82","Fee Schedule","","5.11","52","","","Percent of Total Billed Charges","neg_dollar:$5.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.45","86","","","Percent of Total Billed Charges","neg_dollar:$8.45","6.87","70","","","Percent of Total Billed Charges","neg_dollar:$6.87","5.11","52","","","Percent of Total Billed Charges","neg_dollar:$5.11;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.77;102% of Medicaid interim rate","7.37","75","","","Percent of Total Billed Charges","neg_dollar:$7.37","8.45","86","","","Percent of Total Billed Charges","neg_dollar:$8.45","6.87","70","","","Percent of Total Billed Charges","neg_dollar:$6.87","5.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.60;103.5% of Medicaid interim rate","9.82","150","","","Percent of Total Billed Charges","neg_dollar:$15.19;150% of Medicaid interim rate","7.86","80","","","Percent of Total Billed Charges","neg_dollar:$7.86;Percent of Total Billed Charges","9.04","92","","","Percent of Total Billed Charges","neg_dollar:$9.04","5.11","52","","","Percent of Total Billed Charges","neg_dollar:$5.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.11","52","","","Percent of Total Billed Charges","neg_dollar:$5.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","9.00",""
"ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY","J1650","HCPCS","00781-3238-01","NDC","250","RC","","Facility","Outpatient","30","ME","31.37","31.37","","","","31.37","Fee Schedule","","","","","31.37","Fee Schedule","","","","","24.00","Fee Schedule","","","52","","31.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.31","52","","","Percent of Total Billed Charges","neg_dollar:$16.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.31","52","","","Percent of Total Billed Charges","neg_dollar:$16.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.98","86","","","Percent of Total Billed Charges","neg_dollar:$26.98","21.96","70","","","Percent of Total Billed Charges","neg_dollar:$21.96","","52","","31.37","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","18.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.43;102% of Medicaid interim rate","23.53","75","","","Percent of Total Billed Charges","neg_dollar:$23.53","26.98","86","","","Percent of Total Billed Charges","neg_dollar:$26.98","21.96","70","","","Percent of Total Billed Charges","neg_dollar:$21.96","17.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.88;103.5% of Medicaid interim rate","31.37","150","","","Percent of Total Billed Charges","neg_dollar:$48.51;150% of Medicaid interim rate","25.10","80","","","Percent of Total Billed Charges","neg_dollar:$25.10;Percent of Total Billed Charges","28.86","92","","","Percent of Total Billed Charges","neg_dollar:$28.86","16.31","52","","","Percent of Total Billed Charges","neg_dollar:$16.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","31.37","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","31.00",""
"ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY","J1650","HCPCS","71288-432-80","NDC","636","RC","","Facility","Outpatient","30","ME","31.01","31.01","","","","31.01","Fee Schedule","","","","","31.01","Fee Schedule","101% of Medicare Fee Schedule","","","","24.00","Fee Schedule","","16.12","52","","","Percent of Total Billed Charges","neg_dollar:$16.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","26.67","86","","","Percent of Total Billed Charges","neg_dollar:$26.67","21.71","70","","","Percent of Total Billed Charges","neg_dollar:$21.71","16.12","52","","","Percent of Total Billed Charges","neg_dollar:$16.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","18.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.22;102% of Medicaid interim rate","23.26","75","","","Percent of Total Billed Charges","neg_dollar:$23.26","26.67","86","","","Percent of Total Billed Charges","neg_dollar:$26.67","21.71","70","","","Percent of Total Billed Charges","neg_dollar:$21.71","17.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.67;103.5% of Medicaid interim rate","31.01","150","","","Percent of Total Billed Charges","neg_dollar:$47.95;150% of Medicaid interim rate","24.81","80","","","Percent of Total Billed Charges","neg_dollar:$24.81;Percent of Total Billed Charges","28.53","92","","","Percent of Total Billed Charges","neg_dollar:$28.53","16.12","52","","","Percent of Total Billed Charges","neg_dollar:$16.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.12","52","","","Percent of Total Billed Charges","neg_dollar:$16.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","31.00",""
"ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY","J1650","HCPCS","71288-432-80","NDC","250","RC","","Facility","Outpatient","30","ME","31.01","31.01","","","","31.01","Fee Schedule","","","","","31.01","Fee Schedule","","","","","24.00","Fee Schedule","","","52","","31.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.12","52","","","Percent of Total Billed Charges","neg_dollar:$16.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.12","52","","","Percent of Total Billed Charges","neg_dollar:$16.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.67","86","","","Percent of Total Billed Charges","neg_dollar:$26.67","21.71","70","","","Percent of Total Billed Charges","neg_dollar:$21.71","","52","","31.01","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","18.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.22;102% of Medicaid interim rate","23.26","75","","","Percent of Total Billed Charges","neg_dollar:$23.26","26.67","86","","","Percent of Total Billed Charges","neg_dollar:$26.67","21.71","70","","","Percent of Total Billed Charges","neg_dollar:$21.71","17.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.67;103.5% of Medicaid interim rate","31.01","150","","","Percent of Total Billed Charges","neg_dollar:$47.95;150% of Medicaid interim rate","24.81","80","","","Percent of Total Billed Charges","neg_dollar:$24.81;Percent of Total Billed Charges","28.53","92","","","Percent of Total Billed Charges","neg_dollar:$28.53","16.12","52","","","Percent of Total Billed Charges","neg_dollar:$16.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","31.01","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","31.00",""
"ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY","J1650","HCPCS","00781-3238-01","NDC","636","RC","","Facility","Outpatient","30","ME","32.74","32.74","","","","32.74","Fee Schedule","","","","","32.74","Fee Schedule","101% of Medicare Fee Schedule","","","","24.00","Fee Schedule","","17.02","52","","","Percent of Total Billed Charges","neg_dollar:$17.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","32.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","32.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.16","86","","","Percent of Total Billed Charges","neg_dollar:$28.16","22.92","70","","","Percent of Total Billed Charges","neg_dollar:$22.92","17.02","52","","","Percent of Total Billed Charges","neg_dollar:$17.02;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.23;102% of Medicaid interim rate","24.55","75","","","Percent of Total Billed Charges","neg_dollar:$24.55","28.16","86","","","Percent of Total Billed Charges","neg_dollar:$28.16","22.92","70","","","Percent of Total Billed Charges","neg_dollar:$22.92","18.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.66;103.5% of Medicaid interim rate","32.74","150","","","Percent of Total Billed Charges","neg_dollar:$50.62;150% of Medicaid interim rate","26.19","80","","","Percent of Total Billed Charges","neg_dollar:$26.19;Percent of Total Billed Charges","30.12","92","","","Percent of Total Billed Charges","neg_dollar:$30.12","17.02","52","","","Percent of Total Billed Charges","neg_dollar:$17.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.02","52","","","Percent of Total Billed Charges","neg_dollar:$17.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","32.00",""
"ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY","J1650","HCPCS","00781-3246-02","NDC","250","RC","","Facility","Outpatient","40","ME","23.72","23.72","","","","23.72","Fee Schedule","","","","","23.72","Fee Schedule","","","","","23.72","Fee Schedule","","","52","","23.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.40","86","","","Percent of Total Billed Charges","neg_dollar:$20.40","16.60","70","","","Percent of Total Billed Charges","neg_dollar:$16.60","","52","","23.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.93;102% of Medicaid interim rate","17.79","75","","","Percent of Total Billed Charges","neg_dollar:$17.79","20.40","86","","","Percent of Total Billed Charges","neg_dollar:$20.40","16.60","70","","","Percent of Total Billed Charges","neg_dollar:$16.60","13.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.52;103.5% of Medicaid interim rate","23.72","150","","","Percent of Total Billed Charges","neg_dollar:$36.68;150% of Medicaid interim rate","18.98","80","","","Percent of Total Billed Charges","neg_dollar:$18.98;Percent of Total Billed Charges","21.82","92","","","Percent of Total Billed Charges","neg_dollar:$21.82","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","23.72","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","23.00",""
"ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY","J1650","HCPCS","63323-564-97","NDC","250","RC","","Facility","Outpatient","40","ME","23.72","23.72","","","","23.72","Fee Schedule","","","","","23.72","Fee Schedule","","","","","23.72","Fee Schedule","","","52","","23.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.40","86","","","Percent of Total Billed Charges","neg_dollar:$20.40","16.60","70","","","Percent of Total Billed Charges","neg_dollar:$16.60","","52","","23.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.93;102% of Medicaid interim rate","17.79","75","","","Percent of Total Billed Charges","neg_dollar:$17.79","20.40","86","","","Percent of Total Billed Charges","neg_dollar:$20.40","16.60","70","","","Percent of Total Billed Charges","neg_dollar:$16.60","13.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.52;103.5% of Medicaid interim rate","23.72","150","","","Percent of Total Billed Charges","neg_dollar:$36.68;150% of Medicaid interim rate","18.98","80","","","Percent of Total Billed Charges","neg_dollar:$18.98;Percent of Total Billed Charges","21.82","92","","","Percent of Total Billed Charges","neg_dollar:$21.82","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","23.72","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","23.00",""
"ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY","J1650","HCPCS","00781-3246-02","NDC","636","RC","","Facility","Outpatient","40","ME","23.72","23.72","","","","23.72","Fee Schedule","","","","","23.72","Fee Schedule","101% of Medicare Fee Schedule","","","","23.72","Fee Schedule","","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.40","86","","","Percent of Total Billed Charges","neg_dollar:$20.40","16.60","70","","","Percent of Total Billed Charges","neg_dollar:$16.60","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.93;102% of Medicaid interim rate","17.79","75","","","Percent of Total Billed Charges","neg_dollar:$17.79","20.40","86","","","Percent of Total Billed Charges","neg_dollar:$20.40","16.60","70","","","Percent of Total Billed Charges","neg_dollar:$16.60","13.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.52;103.5% of Medicaid interim rate","23.72","150","","","Percent of Total Billed Charges","neg_dollar:$36.68;150% of Medicaid interim rate","18.98","80","","","Percent of Total Billed Charges","neg_dollar:$18.98;Percent of Total Billed Charges","21.82","92","","","Percent of Total Billed Charges","neg_dollar:$21.82","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","23.00",""
"ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY","J1650","HCPCS","71288-433-82","NDC","250","RC","","Facility","Outpatient","40","ME","23.72","23.72","","","","23.72","Fee Schedule","","","","","23.72","Fee Schedule","","","","","23.72","Fee Schedule","","","52","","23.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.40","86","","","Percent of Total Billed Charges","neg_dollar:$20.40","16.60","70","","","Percent of Total Billed Charges","neg_dollar:$16.60","","52","","23.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.93;102% of Medicaid interim rate","17.79","75","","","Percent of Total Billed Charges","neg_dollar:$17.79","20.40","86","","","Percent of Total Billed Charges","neg_dollar:$20.40","16.60","70","","","Percent of Total Billed Charges","neg_dollar:$16.60","13.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.52;103.5% of Medicaid interim rate","23.72","150","","","Percent of Total Billed Charges","neg_dollar:$36.68;150% of Medicaid interim rate","18.98","80","","","Percent of Total Billed Charges","neg_dollar:$18.98;Percent of Total Billed Charges","21.82","92","","","Percent of Total Billed Charges","neg_dollar:$21.82","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","23.72","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","23.00",""
"ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY","J1650","HCPCS","71288-433-82","NDC","636","RC","","Facility","Outpatient","40","ME","23.72","23.72","","","","23.72","Fee Schedule","","","","","23.72","Fee Schedule","101% of Medicare Fee Schedule","","","","23.72","Fee Schedule","","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.40","86","","","Percent of Total Billed Charges","neg_dollar:$20.40","16.60","70","","","Percent of Total Billed Charges","neg_dollar:$16.60","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.93;102% of Medicaid interim rate","17.79","75","","","Percent of Total Billed Charges","neg_dollar:$17.79","20.40","86","","","Percent of Total Billed Charges","neg_dollar:$20.40","16.60","70","","","Percent of Total Billed Charges","neg_dollar:$16.60","13.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.52;103.5% of Medicaid interim rate","23.72","150","","","Percent of Total Billed Charges","neg_dollar:$36.68;150% of Medicaid interim rate","18.98","80","","","Percent of Total Billed Charges","neg_dollar:$18.98;Percent of Total Billed Charges","21.82","92","","","Percent of Total Billed Charges","neg_dollar:$21.82","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.33","52","","","Percent of Total Billed Charges","neg_dollar:$12.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","23.00",""
"ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY","J1650","HCPCS","71288-434-84","NDC","250","RC","","Facility","Outpatient","60","ME","16.47","16.47","","","","16.47","Fee Schedule","","","","","16.47","Fee Schedule","","","","","16.47","Fee Schedule","","","52","","16.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.56","52","","","Percent of Total Billed Charges","neg_dollar:$8.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.56","52","","","Percent of Total Billed Charges","neg_dollar:$8.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.17","86","","","Percent of Total Billed Charges","neg_dollar:$14.17","11.53","70","","","Percent of Total Billed Charges","neg_dollar:$11.53","","52","","16.47","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.68;102% of Medicaid interim rate","12.35","75","","","Percent of Total Billed Charges","neg_dollar:$12.35","14.17","86","","","Percent of Total Billed Charges","neg_dollar:$14.17","11.53","70","","","Percent of Total Billed Charges","neg_dollar:$11.53","9.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.39;103.5% of Medicaid interim rate","16.47","150","","","Percent of Total Billed Charges","neg_dollar:$25.47;150% of Medicaid interim rate","13.18","80","","","Percent of Total Billed Charges","neg_dollar:$13.18;Percent of Total Billed Charges","15.15","92","","","Percent of Total Billed Charges","neg_dollar:$15.15","8.56","52","","","Percent of Total Billed Charges","neg_dollar:$8.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","16.47","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","16.00",""
"ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY","J1650","HCPCS","71288-434-84","NDC","636","RC","","Facility","Outpatient","60","ME","16.65","16.65","","","","16.65","Fee Schedule","","","","","16.65","Fee Schedule","101% of Medicare Fee Schedule","","","","16.65","Fee Schedule","","8.65","52","","","Percent of Total Billed Charges","neg_dollar:$8.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","16.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.31","86","","","Percent of Total Billed Charges","neg_dollar:$14.31","11.65","70","","","Percent of Total Billed Charges","neg_dollar:$11.65","8.65","52","","","Percent of Total Billed Charges","neg_dollar:$8.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.78;102% of Medicaid interim rate","12.48","75","","","Percent of Total Billed Charges","neg_dollar:$12.48","14.31","86","","","Percent of Total Billed Charges","neg_dollar:$14.31","11.65","70","","","Percent of Total Billed Charges","neg_dollar:$11.65","9.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.49;103.5% of Medicaid interim rate","16.65","150","","","Percent of Total Billed Charges","neg_dollar:$25.74;150% of Medicaid interim rate","13.32","80","","","Percent of Total Billed Charges","neg_dollar:$13.32;Percent of Total Billed Charges","15.31","92","","","Percent of Total Billed Charges","neg_dollar:$15.31","8.65","52","","","Percent of Total Billed Charges","neg_dollar:$8.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.65","52","","","Percent of Total Billed Charges","neg_dollar:$8.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","16.00",""
"ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY","J1650","HCPCS","71288-435-86","NDC","250","RC","","Facility","Outpatient","80","ME","13.91","13.91","","","","13.91","Fee Schedule","","","","","13.91","Fee Schedule","","","","","13.91","Fee Schedule","","","52","","13.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.23","52","","","Percent of Total Billed Charges","neg_dollar:$7.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.23","52","","","Percent of Total Billed Charges","neg_dollar:$7.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.97","86","","","Percent of Total Billed Charges","neg_dollar:$11.97","9.74","70","","","Percent of Total Billed Charges","neg_dollar:$9.74","","52","","13.91","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.17;102% of Medicaid interim rate","10.43","75","","","Percent of Total Billed Charges","neg_dollar:$10.43","11.97","86","","","Percent of Total Billed Charges","neg_dollar:$11.97","9.74","70","","","Percent of Total Billed Charges","neg_dollar:$9.74","7.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.93;103.5% of Medicaid interim rate","13.91","150","","","Percent of Total Billed Charges","neg_dollar:$21.51;150% of Medicaid interim rate","11.13","80","","","Percent of Total Billed Charges","neg_dollar:$11.13;Percent of Total Billed Charges","12.80","92","","","Percent of Total Billed Charges","neg_dollar:$12.80","7.23","52","","","Percent of Total Billed Charges","neg_dollar:$7.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","13.91","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","13.00",""
"ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY","J1650","HCPCS","00955-1008-10","NDC","250","RC","","Facility","Outpatient","80","ME","15.94","15.94","","","","15.94","Fee Schedule","","","","","15.94","Fee Schedule","","","","","15.94","Fee Schedule","","","52","","15.94","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.29","52","","","Percent of Total Billed Charges","neg_dollar:$8.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.29","52","","","Percent of Total Billed Charges","neg_dollar:$8.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.71","86","","","Percent of Total Billed Charges","neg_dollar:$13.71","11.16","70","","","Percent of Total Billed Charges","neg_dollar:$11.16","","52","","15.94","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.36;102% of Medicaid interim rate","11.95","75","","","Percent of Total Billed Charges","neg_dollar:$11.95","13.71","86","","","Percent of Total Billed Charges","neg_dollar:$13.71","11.16","70","","","Percent of Total Billed Charges","neg_dollar:$11.16","9.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.08;103.5% of Medicaid interim rate","15.94","150","","","Percent of Total Billed Charges","neg_dollar:$24.64;150% of Medicaid interim rate","12.75","80","","","Percent of Total Billed Charges","neg_dollar:$12.75;Percent of Total Billed Charges","14.66","92","","","Percent of Total Billed Charges","neg_dollar:$14.66","8.29","52","","","Percent of Total Billed Charges","neg_dollar:$8.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","15.94","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","15.00",""
"ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY","J1650","HCPCS","00955-1008-10","NDC","636","RC","","Facility","Outpatient","80","ME","15.94","15.94","","","","15.94","Fee Schedule","","","","","15.94","Fee Schedule","101% of Medicare Fee Schedule","","","","15.94","Fee Schedule","","8.29","52","","","Percent of Total Billed Charges","neg_dollar:$8.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","15.94","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","15.94","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.71","86","","","Percent of Total Billed Charges","neg_dollar:$13.71","11.16","70","","","Percent of Total Billed Charges","neg_dollar:$11.16","8.29","52","","","Percent of Total Billed Charges","neg_dollar:$8.29;105% Medicare Outpatient Cost to Charge Ratio of 52%","9.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.36;102% of Medicaid interim rate","11.95","75","","","Percent of Total Billed Charges","neg_dollar:$11.95","13.71","86","","","Percent of Total Billed Charges","neg_dollar:$13.71","11.16","70","","","Percent of Total Billed Charges","neg_dollar:$11.16","9.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.08;103.5% of Medicaid interim rate","15.94","150","","","Percent of Total Billed Charges","neg_dollar:$24.64;150% of Medicaid interim rate","12.75","80","","","Percent of Total Billed Charges","neg_dollar:$12.75;Percent of Total Billed Charges","14.66","92","","","Percent of Total Billed Charges","neg_dollar:$14.66","8.29","52","","","Percent of Total Billed Charges","neg_dollar:$8.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.29","52","","","Percent of Total Billed Charges","neg_dollar:$8.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","15.00",""
"HYDROCORTISONE SOD SUC (PF) 100 MG IJ SOLR","J1720","HCPCS","00009-0011-03","NDC","636","RC","","Facility","Outpatient","100","ME","112","112.00","","","","112.00","Fee Schedule","","","","","112.00","Fee Schedule","101% of Medicare Fee Schedule","","","","112.00","Fee Schedule","","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","112.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","112.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","96.32","86","","","Percent of Total Billed Charges","neg_dollar:$96.32","78.40","70","","","Percent of Total Billed Charges","neg_dollar:$78.40","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","65.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$65.80;102% of Medicaid interim rate","84.00","75","","","Percent of Total Billed Charges","neg_dollar:$84","96.32","86","","","Percent of Total Billed Charges","neg_dollar:$96.32","78.40","70","","","Percent of Total Billed Charges","neg_dollar:$78.40","63.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$63.84;103.5% of Medicaid interim rate","112.00","150","","","Percent of Total Billed Charges","neg_dollar:$173.16;150% of Medicaid interim rate","89.60","80","","","Percent of Total Billed Charges","neg_dollar:$89.60;Percent of Total Billed Charges","103.04","92","","","Percent of Total Billed Charges","neg_dollar:$103.04","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.24","52","","","Percent of Total Billed Charges","neg_dollar:$58.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.00","112.00",""
"HYDROCORTISONE SOD SUC (PF) 100 MG IJ SOLR","J1720","HCPCS","00009-0011-04","NDC","636","RC","","Facility","Outpatient","100","ME","108.95","108.95","","","","108.95","Fee Schedule","","","","","108.95","Fee Schedule","101% of Medicare Fee Schedule","","","","108.95","Fee Schedule","","56.65","52","","","Percent of Total Billed Charges","neg_dollar:$56.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","108.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","108.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","93.69","86","","","Percent of Total Billed Charges","neg_dollar:$93.69","76.26","70","","","Percent of Total Billed Charges","neg_dollar:$76.26","56.65","52","","","Percent of Total Billed Charges","neg_dollar:$56.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","64.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$64;102% of Medicaid interim rate","81.71","75","","","Percent of Total Billed Charges","neg_dollar:$81.71","93.69","86","","","Percent of Total Billed Charges","neg_dollar:$93.69","76.26","70","","","Percent of Total Billed Charges","neg_dollar:$76.26","62.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$62.10;103.5% of Medicaid interim rate","108.95","150","","","Percent of Total Billed Charges","neg_dollar:$168.44;150% of Medicaid interim rate","87.16","80","","","Percent of Total Billed Charges","neg_dollar:$87.16;Percent of Total Billed Charges","100.23","92","","","Percent of Total Billed Charges","neg_dollar:$100.23","56.65","52","","","Percent of Total Billed Charges","neg_dollar:$56.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","56.65","52","","","Percent of Total Billed Charges","neg_dollar:$56.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","56.00","108.00",""
"IRON SUCROSE 20 MG/ML IV SOLN","J1756","HCPCS","00517-2310-01","NDC","250","RC","","Facility","Outpatient","1","ML","1.69","1.69","","","","1.69","Fee Schedule","","","","","1.69","Fee Schedule","","","","","1.69","Fee Schedule","","","52","","1.69","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.18","70","","","Percent of Total Billed Charges","neg_dollar:$1.18","","52","","1.69","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.18","70","","","Percent of Total Billed Charges","neg_dollar:$1.18","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.69","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.35","80","","","Percent of Total Billed Charges","neg_dollar:$1.35;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.69","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"IRON SUCROSE 20 MG/ML IV SOLN","J1756","HCPCS","00517-2310-01","NDC","636","RC","","Facility","Outpatient","1","ML","2.13","2.13","","","","2.13","Fee Schedule","","","","","2.13","Fee Schedule","101% of Medicare Fee Schedule","","","","2.13","Fee Schedule","","1.11","52","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.83","86","","","Percent of Total Billed Charges","neg_dollar:$1.83","1.49","70","","","Percent of Total Billed Charges","neg_dollar:$1.49","1.11","52","","","Percent of Total Billed Charges","neg_dollar:$1.11;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.25;102% of Medicaid interim rate","1.60","75","","","Percent of Total Billed Charges","neg_dollar:$1.60","1.83","86","","","Percent of Total Billed Charges","neg_dollar:$1.83","1.49","70","","","Percent of Total Billed Charges","neg_dollar:$1.49","1.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.21;103.5% of Medicaid interim rate","2.13","150","","","Percent of Total Billed Charges","neg_dollar:$3.30;150% of Medicaid interim rate","1.70","80","","","Percent of Total Billed Charges","neg_dollar:$1.70;Percent of Total Billed Charges","1.96","92","","","Percent of Total Billed Charges","neg_dollar:$1.96","1.11","52","","","Percent of Total Billed Charges","neg_dollar:$1.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","52","","","Percent of Total Billed Charges","neg_dollar:$1.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"IRON SUCROSE 20 MG/ML IV SOLN","J1756","HCPCS","00517-2310-05","NDC","636","RC","","Facility","Outpatient","1","ML","1.64","1.64","","","","1.64","Fee Schedule","","","","","1.64","Fee Schedule","101% of Medicare Fee Schedule","","","","1.64","Fee Schedule","","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.23","75","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;103.5% of Medicaid interim rate","1.64","150","","","Percent of Total Billed Charges","neg_dollar:$2.54;150% of Medicaid interim rate","1.31","80","","","Percent of Total Billed Charges","neg_dollar:$1.31;Percent of Total Billed Charges","1.51","92","","","Percent of Total Billed Charges","neg_dollar:$1.51","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"IRON SUCROSE 20 MG/ML IV SOLN","J1756","HCPCS","00517-2310-05","NDC","636","RC","","Facility","Outpatient","1","ML","1.65","1.65","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","101% of Medicare Fee Schedule","","","","1.65","Fee Schedule","","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.42","86","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.16","70","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.97;102% of Medicaid interim rate","1.24","75","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.42","86","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.16","70","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.65","150","","","Percent of Total Billed Charges","neg_dollar:$2.56;150% of Medicaid interim rate","1.32","80","","","Percent of Total Billed Charges","neg_dollar:$1.32;Percent of Total Billed Charges","1.52","92","","","Percent of Total Billed Charges","neg_dollar:$1.52","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"IRON SUCROSE 20 MG/ML IV SOLN","J1756","HCPCS","00517-2310-01","NDC","636","RC","","Facility","Outpatient","1","ML","1.63","1.63","","","","1.63","Fee Schedule","","","","","1.63","Fee Schedule","101% of Medicare Fee Schedule","","","","1.63","Fee Schedule","","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","86","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","70","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% of Medicaid interim rate","1.22","75","","","Percent of Total Billed Charges","neg_dollar:$1.22","1.40","86","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","70","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.92;103.5% of Medicaid interim rate","1.63","150","","","Percent of Total Billed Charges","neg_dollar:$2.52;150% of Medicaid interim rate","1.30","80","","","Percent of Total Billed Charges","neg_dollar:$1.30;Percent of Total Billed Charges","1.50","92","","","Percent of Total Billed Charges","neg_dollar:$1.50","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"IRON SUCROSE 20 MG/ML IV SOLN","J1756","HCPCS","00517-2310-01","NDC","636","RC","","Facility","Outpatient","1","ML","1.72","1.72","","","","1.72","Fee Schedule","","","","","1.72","Fee Schedule","101% of Medicare Fee Schedule","","","","1.72","Fee Schedule","","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.48","86","","","Percent of Total Billed Charges","neg_dollar:$1.48","1.20","70","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.01;102% of Medicaid interim rate","1.29","75","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.48","86","","","Percent of Total Billed Charges","neg_dollar:$1.48","1.20","70","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.98;103.5% of Medicaid interim rate","1.72","150","","","Percent of Total Billed Charges","neg_dollar:$2.66;150% of Medicaid interim rate","1.38","80","","","Percent of Total Billed Charges","neg_dollar:$1.38;Percent of Total Billed Charges","1.58","92","","","Percent of Total Billed Charges","neg_dollar:$1.58","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"IRON SUCROSE 20 MG/ML IV SOLN","J1756","HCPCS","00517-2310-05","NDC","636","RC","","Facility","Outpatient","1","ML","1.27","1.27","","","","1.27","Fee Schedule","","","","","1.27","Fee Schedule","101% of Medicare Fee Schedule","","","","1.27","Fee Schedule","","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.10","86","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.89","70","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% of Medicaid interim rate","0.95","75","","","Percent of Total Billed Charges","neg_dollar:$0.95","1.10","86","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.89","70","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.72;103.5% of Medicaid interim rate","1.27","150","","","Percent of Total Billed Charges","neg_dollar:$1.97;150% of Medicaid interim rate","1.02","80","","","Percent of Total Billed Charges","neg_dollar:$1.02;Percent of Total Billed Charges","1.17","92","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DROPERIDOL 2.5 MG/ML IJ SOLN","J1790","HCPCS","00517-9702-25","NDC","636","RC","","Facility","Outpatient","1","ML","93.51","93.51","","","","34.00","Fee Schedule","","","","","47.00","Fee Schedule","101% of Medicare Fee Schedule","","","","9.00","Fee Schedule","","48.62","52","","","Percent of Total Billed Charges","neg_dollar:$48.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","93.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","93.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","80.42","86","","","Percent of Total Billed Charges","neg_dollar:$80.42","65.46","70","","","Percent of Total Billed Charges","neg_dollar:$65.46","48.62","52","","","Percent of Total Billed Charges","neg_dollar:$48.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","54.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.94;102% of Medicaid interim rate","70.13","75","","","Percent of Total Billed Charges","neg_dollar:$70.13","80.42","86","","","Percent of Total Billed Charges","neg_dollar:$80.42","65.46","70","","","Percent of Total Billed Charges","neg_dollar:$65.46","53.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.30;103.5% of Medicaid interim rate","93.51","150","","","Percent of Total Billed Charges","neg_dollar:$144.58;150% of Medicaid interim rate","74.81","80","","","Percent of Total Billed Charges","neg_dollar:$74.81;Percent of Total Billed Charges","86.03","92","","","Percent of Total Billed Charges","neg_dollar:$86.03","48.62","52","","","Percent of Total Billed Charges","neg_dollar:$48.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.62","52","","","Percent of Total Billed Charges","neg_dollar:$48.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","93.00",""
"ESMOLOL HCL 100 MG/10ML IV SOLN","J1805","HCPCS","55150-194-10","NDC","636","RC","","Facility","Outpatient","1","UN","0.45","0.45","","","","0.45","Fee Schedule","","","","","0.45","Fee Schedule","101% of Medicare Fee Schedule","","","","0.45","Fee Schedule","","0.23","52","","","Percent of Total Billed Charges","neg_dollar:$0.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.38","86","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.31","70","","","Percent of Total Billed Charges","neg_dollar:$0.31","0.23","52","","","Percent of Total Billed Charges","neg_dollar:$0.23;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% of Medicaid interim rate","0.33","75","","","Percent of Total Billed Charges","neg_dollar:$0.33","0.38","86","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.31","70","","","Percent of Total Billed Charges","neg_dollar:$0.31","0.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.25;103.5% of Medicaid interim rate","0.45","150","","","Percent of Total Billed Charges","neg_dollar:$0.69;150% of Medicaid interim rate","0.36","80","","","Percent of Total Billed Charges","neg_dollar:$0.36;Percent of Total Billed Charges","0.41","92","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.23","52","","","Percent of Total Billed Charges","neg_dollar:$0.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.23","52","","","Percent of Total Billed Charges","neg_dollar:$0.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ESMOLOL HCL 100 MG/10ML IV SOLN","J1805","HCPCS","55150-194-10","NDC","636","RC","","Facility","Outpatient","1","UN","9.63","9.63","","","","9.63","Fee Schedule","","","","","9.63","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","5.00","52","","","Percent of Total Billed Charges","neg_dollar:$5;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.28","86","","","Percent of Total Billed Charges","neg_dollar:$8.28","6.74","70","","","Percent of Total Billed Charges","neg_dollar:$6.74","5.00","52","","","Percent of Total Billed Charges","neg_dollar:$5;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.65;102% of Medicaid interim rate","7.22","75","","","Percent of Total Billed Charges","neg_dollar:$7.22","8.28","86","","","Percent of Total Billed Charges","neg_dollar:$8.28","6.74","70","","","Percent of Total Billed Charges","neg_dollar:$6.74","5.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.48;103.5% of Medicaid interim rate","9.63","150","","","Percent of Total Billed Charges","neg_dollar:$14.88;150% of Medicaid interim rate","7.70","80","","","Percent of Total Billed Charges","neg_dollar:$7.70;Percent of Total Billed Charges","8.85","92","","","Percent of Total Billed Charges","neg_dollar:$8.85","5.00","52","","","Percent of Total Billed Charges","neg_dollar:$5;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","52","","","Percent of Total Billed Charges","neg_dollar:$5;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","9.00",""
"METRONIDAZOLE 500 MG/100ML IV SOLN","J1836","HCPCS","25021-131-82","NDC","250","RC","","Facility","Outpatient","1","UN","1.84","1.84","","","","1.84","Fee Schedule","","","","","1.84","Fee Schedule","","","","","1.84","Fee Schedule","","","52","","1.84","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","86","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","","52","","1.84","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.58","86","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","1.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.04;103.5% of Medicaid interim rate","1.84","150","","","Percent of Total Billed Charges","neg_dollar:$2.84;150% of Medicaid interim rate","1.47","80","","","Percent of Total Billed Charges","neg_dollar:$1.47;Percent of Total Billed Charges","1.69","92","","","Percent of Total Billed Charges","neg_dollar:$1.69","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.84","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METRONIDAZOLE 500 MG/100ML IV SOLN","J1836","HCPCS","00338-1055-48","NDC","636","RC","","Facility","Outpatient","1","UN","1.84","1.84","","","","1.84","Fee Schedule","","","","","1.84","Fee Schedule","101% of Medicare Fee Schedule","","","","1.84","Fee Schedule","","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.84","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.84","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","86","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.58","86","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","1.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.04;103.5% of Medicaid interim rate","1.84","150","","","Percent of Total Billed Charges","neg_dollar:$2.84;150% of Medicaid interim rate","1.47","80","","","Percent of Total Billed Charges","neg_dollar:$1.47;Percent of Total Billed Charges","1.69","92","","","Percent of Total Billed Charges","neg_dollar:$1.69","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METRONIDAZOLE 500 MG/100ML IV SOLN","J1836","HCPCS","00338-1055-48","NDC","250","RC","","Facility","Outpatient","1","UN","1.84","1.84","","","","1.84","Fee Schedule","","","","","1.84","Fee Schedule","","","","","1.84","Fee Schedule","","","52","","1.84","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","86","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","","52","","1.84","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.58","86","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","1.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.04;103.5% of Medicaid interim rate","1.84","150","","","Percent of Total Billed Charges","neg_dollar:$2.84;150% of Medicaid interim rate","1.47","80","","","Percent of Total Billed Charges","neg_dollar:$1.47;Percent of Total Billed Charges","1.69","92","","","Percent of Total Billed Charges","neg_dollar:$1.69","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.84","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METRONIDAZOLE 500 MG/100ML IV SOLN","J1836","HCPCS","25021-131-82","NDC","636","RC","","Facility","Outpatient","1","UN","1.84","1.84","","","","1.84","Fee Schedule","","","","","1.84","Fee Schedule","101% of Medicare Fee Schedule","","","","1.84","Fee Schedule","","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.84","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.84","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","86","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.58","86","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","1.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.04;103.5% of Medicaid interim rate","1.84","150","","","Percent of Total Billed Charges","neg_dollar:$2.84;150% of Medicaid interim rate","1.47","80","","","Percent of Total Billed Charges","neg_dollar:$1.47;Percent of Total Billed Charges","1.69","92","","","Percent of Total Billed Charges","neg_dollar:$1.69","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN","J1885","HCPCS","31722-305-01","NDC","250","RC","","Facility","Outpatient","1","ML","91.30","91.30","","","","1.00","Fee Schedule","","","","","50.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","91.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.47","52","","","Percent of Total Billed Charges","neg_dollar:$47.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.47","52","","","Percent of Total Billed Charges","neg_dollar:$47.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.51","86","","","Percent of Total Billed Charges","neg_dollar:$78.51","63.91","70","","","Percent of Total Billed Charges","neg_dollar:$63.91","","52","","76.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.63;102% of Medicaid interim rate","68.47","75","","","Percent of Total Billed Charges","neg_dollar:$68.47","78.51","86","","","Percent of Total Billed Charges","neg_dollar:$78.51","63.91","70","","","Percent of Total Billed Charges","neg_dollar:$63.91","52.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.04;103.5% of Medicaid interim rate","91.30","150","","","Percent of Total Billed Charges","neg_dollar:$141.15;150% of Medicaid interim rate","73.04","80","","","Percent of Total Billed Charges","neg_dollar:$73.04;Percent of Total Billed Charges","83.99","92","","","Percent of Total Billed Charges","neg_dollar:$83.99","47.47","52","","","Percent of Total Billed Charges","neg_dollar:$47.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","57.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN","J1885","HCPCS","63323-161-01","NDC","636","RC","","Facility","Outpatient","1","ML","95","95.00","","","","1.00","Fee Schedule","","","","","50.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","49.40","52","","","Percent of Total Billed Charges","neg_dollar:$49.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","95.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","95.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","81.70","86","","","Percent of Total Billed Charges","neg_dollar:$81.70","66.50","70","","","Percent of Total Billed Charges","neg_dollar:$66.50","49.40","52","","","Percent of Total Billed Charges","neg_dollar:$49.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","55.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.81;102% of Medicaid interim rate","71.25","75","","","Percent of Total Billed Charges","neg_dollar:$71.25","81.70","86","","","Percent of Total Billed Charges","neg_dollar:$81.70","66.50","70","","","Percent of Total Billed Charges","neg_dollar:$66.50","54.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.15;103.5% of Medicaid interim rate","95.00","150","","","Percent of Total Billed Charges","neg_dollar:$146.87;150% of Medicaid interim rate","76.00","80","","","Percent of Total Billed Charges","neg_dollar:$76;Percent of Total Billed Charges","87.40","92","","","Percent of Total Billed Charges","neg_dollar:$87.40","49.40","52","","","Percent of Total Billed Charges","neg_dollar:$49.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","49.40","52","","","Percent of Total Billed Charges","neg_dollar:$49.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","95.00",""
"KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN","J1885","HCPCS","63323-161-01","NDC","250","RC","","Facility","Outpatient","1","ML","95","95.00","","","","1.00","Fee Schedule","","","","","50.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","95.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","49.40","52","","","Percent of Total Billed Charges","neg_dollar:$49.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","49.40","52","","","Percent of Total Billed Charges","neg_dollar:$49.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","81.70","86","","","Percent of Total Billed Charges","neg_dollar:$81.70","66.50","70","","","Percent of Total Billed Charges","neg_dollar:$66.50","","52","","76.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","55.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.81;102% of Medicaid interim rate","71.25","75","","","Percent of Total Billed Charges","neg_dollar:$71.25","81.70","86","","","Percent of Total Billed Charges","neg_dollar:$81.70","66.50","70","","","Percent of Total Billed Charges","neg_dollar:$66.50","54.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.15;103.5% of Medicaid interim rate","95.00","150","","","Percent of Total Billed Charges","neg_dollar:$146.87;150% of Medicaid interim rate","76.00","80","","","Percent of Total Billed Charges","neg_dollar:$76;Percent of Total Billed Charges","87.40","92","","","Percent of Total Billed Charges","neg_dollar:$87.40","49.40","52","","","Percent of Total Billed Charges","neg_dollar:$49.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","57.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","95.00",""
"KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN","J1885","HCPCS","31722-305-01","NDC","636","RC","","Facility","Outpatient","1","ML","91.30","91.30","","","","1.00","Fee Schedule","","","","","50.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","47.47","52","","","Percent of Total Billed Charges","neg_dollar:$47.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.51","86","","","Percent of Total Billed Charges","neg_dollar:$78.51","63.91","70","","","Percent of Total Billed Charges","neg_dollar:$63.91","47.47","52","","","Percent of Total Billed Charges","neg_dollar:$47.47;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.63;102% of Medicaid interim rate","68.47","75","","","Percent of Total Billed Charges","neg_dollar:$68.47","78.51","86","","","Percent of Total Billed Charges","neg_dollar:$78.51","63.91","70","","","Percent of Total Billed Charges","neg_dollar:$63.91","52.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.04;103.5% of Medicaid interim rate","91.30","150","","","Percent of Total Billed Charges","neg_dollar:$141.15;150% of Medicaid interim rate","73.04","80","","","Percent of Total Billed Charges","neg_dollar:$73.04;Percent of Total Billed Charges","83.99","92","","","Percent of Total Billed Charges","neg_dollar:$83.99","47.47","52","","","Percent of Total Billed Charges","neg_dollar:$47.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.47","52","","","Percent of Total Billed Charges","neg_dollar:$47.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN","J1885","HCPCS","31722-305-25","NDC","636","RC","","Facility","Outpatient","1","ML","91.25","91.25","","","","1.00","Fee Schedule","","","","","50.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","47.45","52","","","Percent of Total Billed Charges","neg_dollar:$47.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.47","86","","","Percent of Total Billed Charges","neg_dollar:$78.47","63.87","70","","","Percent of Total Billed Charges","neg_dollar:$63.87","47.45","52","","","Percent of Total Billed Charges","neg_dollar:$47.45;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.60;102% of Medicaid interim rate","68.43","75","","","Percent of Total Billed Charges","neg_dollar:$68.43","78.47","86","","","Percent of Total Billed Charges","neg_dollar:$78.47","63.87","70","","","Percent of Total Billed Charges","neg_dollar:$63.87","52.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.01;103.5% of Medicaid interim rate","91.25","150","","","Percent of Total Billed Charges","neg_dollar:$141.07;150% of Medicaid interim rate","73.00","80","","","Percent of Total Billed Charges","neg_dollar:$73;Percent of Total Billed Charges","83.95","92","","","Percent of Total Billed Charges","neg_dollar:$83.95","47.45","52","","","Percent of Total Billed Charges","neg_dollar:$47.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.45","52","","","Percent of Total Billed Charges","neg_dollar:$47.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN","J1885","HCPCS","00409-3793-19","NDC","636","RC","","Facility","Outpatient","1","ML","93.55","93.55","","","","1.00","Fee Schedule","","","","","50.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","48.64","52","","","Percent of Total Billed Charges","neg_dollar:$48.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","93.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","93.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","80.45","86","","","Percent of Total Billed Charges","neg_dollar:$80.45","65.48","70","","","Percent of Total Billed Charges","neg_dollar:$65.48","48.64","52","","","Percent of Total Billed Charges","neg_dollar:$48.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","54.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.96;102% of Medicaid interim rate","70.16","75","","","Percent of Total Billed Charges","neg_dollar:$70.16","80.45","86","","","Percent of Total Billed Charges","neg_dollar:$80.45","65.48","70","","","Percent of Total Billed Charges","neg_dollar:$65.48","53.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.32;103.5% of Medicaid interim rate","93.55","150","","","Percent of Total Billed Charges","neg_dollar:$144.63;150% of Medicaid interim rate","74.84","80","","","Percent of Total Billed Charges","neg_dollar:$74.84;Percent of Total Billed Charges","86.06","92","","","Percent of Total Billed Charges","neg_dollar:$86.06","48.64","52","","","Percent of Total Billed Charges","neg_dollar:$48.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.64","52","","","Percent of Total Billed Charges","neg_dollar:$48.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","93.00",""
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","J1885","HCPCS","72266-118-01","NDC","250","RC","","Facility","Outpatient","1","ML","45.50","45.50","","","","1.00","Fee Schedule","","","","","45.50","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","45.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","39.13","86","","","Percent of Total Billed Charges","neg_dollar:$39.13","31.84","70","","","Percent of Total Billed Charges","neg_dollar:$31.84","","52","","45.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","26.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.73;102% of Medicaid interim rate","34.12","75","","","Percent of Total Billed Charges","neg_dollar:$34.12","39.13","86","","","Percent of Total Billed Charges","neg_dollar:$39.13","31.84","70","","","Percent of Total Billed Charges","neg_dollar:$31.84","25.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.93;103.5% of Medicaid interim rate","45.50","150","","","Percent of Total Billed Charges","neg_dollar:$70.34;150% of Medicaid interim rate","36.40","80","","","Percent of Total Billed Charges","neg_dollar:$36.40;Percent of Total Billed Charges","41.86","92","","","Percent of Total Billed Charges","neg_dollar:$41.86","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","45.50","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","45.00",""
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","J1885","HCPCS","62332-600-01","NDC","636","RC","","Facility","Outpatient","1","ML","45.65","45.65","","","","1.00","Fee Schedule","","","","","45.65","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","23.73","52","","","Percent of Total Billed Charges","neg_dollar:$23.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","45.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","45.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","39.25","86","","","Percent of Total Billed Charges","neg_dollar:$39.25","31.95","70","","","Percent of Total Billed Charges","neg_dollar:$31.95","23.73","52","","","Percent of Total Billed Charges","neg_dollar:$23.73;105% Medicare Outpatient Cost to Charge Ratio of 52%","26.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.81;102% of Medicaid interim rate","34.23","75","","","Percent of Total Billed Charges","neg_dollar:$34.23","39.25","86","","","Percent of Total Billed Charges","neg_dollar:$39.25","31.95","70","","","Percent of Total Billed Charges","neg_dollar:$31.95","26.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.02;103.5% of Medicaid interim rate","45.65","150","","","Percent of Total Billed Charges","neg_dollar:$70.57;150% of Medicaid interim rate","36.52","80","","","Percent of Total Billed Charges","neg_dollar:$36.52;Percent of Total Billed Charges","41.99","92","","","Percent of Total Billed Charges","neg_dollar:$41.99","23.73","52","","","Percent of Total Billed Charges","neg_dollar:$23.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.73","52","","","Percent of Total Billed Charges","neg_dollar:$23.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","45.00",""
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","J1885","HCPCS","72266-118-01","NDC","636","RC","","Facility","Outpatient","1","ML","45.50","45.50","","","","1.00","Fee Schedule","","","","","45.50","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","45.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","45.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","39.13","86","","","Percent of Total Billed Charges","neg_dollar:$39.13","31.84","70","","","Percent of Total Billed Charges","neg_dollar:$31.84","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;105% Medicare Outpatient Cost to Charge Ratio of 52%","26.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.73;102% of Medicaid interim rate","34.12","75","","","Percent of Total Billed Charges","neg_dollar:$34.12","39.13","86","","","Percent of Total Billed Charges","neg_dollar:$39.13","31.84","70","","","Percent of Total Billed Charges","neg_dollar:$31.84","25.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.93;103.5% of Medicaid interim rate","45.50","150","","","Percent of Total Billed Charges","neg_dollar:$70.34;150% of Medicaid interim rate","36.40","80","","","Percent of Total Billed Charges","neg_dollar:$36.40;Percent of Total Billed Charges","41.86","92","","","Percent of Total Billed Charges","neg_dollar:$41.86","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","45.00",""
"KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN","J1885","HCPCS","72266-118-25","NDC","636","RC","","Facility","Outpatient","1","ML","45.50","45.50","","","","1.00","Fee Schedule","","","","","45.50","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","45.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","45.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","39.13","86","","","Percent of Total Billed Charges","neg_dollar:$39.13","31.84","70","","","Percent of Total Billed Charges","neg_dollar:$31.84","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;105% Medicare Outpatient Cost to Charge Ratio of 52%","26.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.73;102% of Medicaid interim rate","34.12","75","","","Percent of Total Billed Charges","neg_dollar:$34.12","39.13","86","","","Percent of Total Billed Charges","neg_dollar:$39.13","31.84","70","","","Percent of Total Billed Charges","neg_dollar:$31.84","25.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.93;103.5% of Medicaid interim rate","45.50","150","","","Percent of Total Billed Charges","neg_dollar:$70.34;150% of Medicaid interim rate","36.40","80","","","Percent of Total Billed Charges","neg_dollar:$36.40;Percent of Total Billed Charges","41.86","92","","","Percent of Total Billed Charges","neg_dollar:$41.86","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.66","52","","","Percent of Total Billed Charges","neg_dollar:$23.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","45.00",""
"KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN","J1885","HCPCS","00409-3796-01","NDC","636","RC","","Facility","Outpatient","2","ML","22.51","22.51","","","","1.00","Fee Schedule","","","","","22.51","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","11.70","52","","","Percent of Total Billed Charges","neg_dollar:$11.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","22.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","22.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","19.36","86","","","Percent of Total Billed Charges","neg_dollar:$19.36","15.76","70","","","Percent of Total Billed Charges","neg_dollar:$15.76","11.70","52","","","Percent of Total Billed Charges","neg_dollar:$11.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.22;102% of Medicaid interim rate","16.88","75","","","Percent of Total Billed Charges","neg_dollar:$16.88","19.36","86","","","Percent of Total Billed Charges","neg_dollar:$19.36","15.76","70","","","Percent of Total Billed Charges","neg_dollar:$15.76","12.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.83;103.5% of Medicaid interim rate","22.51","150","","","Percent of Total Billed Charges","neg_dollar:$34.81;150% of Medicaid interim rate","18.01","80","","","Percent of Total Billed Charges","neg_dollar:$18.01;Percent of Total Billed Charges","20.71","92","","","Percent of Total Billed Charges","neg_dollar:$20.71","11.70","52","","","Percent of Total Billed Charges","neg_dollar:$11.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.70","52","","","Percent of Total Billed Charges","neg_dollar:$11.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","22.00",""
"KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN","J1885","HCPCS","63323-162-26","NDC","636","RC","","Facility","Outpatient","2","ML","27.57","27.57","","","","1.00","Fee Schedule","","","","","27.57","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","14.33","52","","","Percent of Total Billed Charges","neg_dollar:$14.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","27.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","27.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","23.71","86","","","Percent of Total Billed Charges","neg_dollar:$23.71","19.30","70","","","Percent of Total Billed Charges","neg_dollar:$19.30","14.33","52","","","Percent of Total Billed Charges","neg_dollar:$14.33;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.20;102% of Medicaid interim rate","20.68","75","","","Percent of Total Billed Charges","neg_dollar:$20.68","23.71","86","","","Percent of Total Billed Charges","neg_dollar:$23.71","19.30","70","","","Percent of Total Billed Charges","neg_dollar:$19.30","15.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.71;103.5% of Medicaid interim rate","27.57","150","","","Percent of Total Billed Charges","neg_dollar:$42.63;150% of Medicaid interim rate","22.06","80","","","Percent of Total Billed Charges","neg_dollar:$22.06;Percent of Total Billed Charges","25.36","92","","","Percent of Total Billed Charges","neg_dollar:$25.36","14.33","52","","","Percent of Total Billed Charges","neg_dollar:$14.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.33","52","","","Percent of Total Billed Charges","neg_dollar:$14.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","27.00",""
"KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN","J1885","HCPCS","00409-3796-01","NDC","636","RC","","Facility","Outpatient","2","ML","8.97","8.97","","","","1.00","Fee Schedule","","","","","8.97","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","4.66","52","","","Percent of Total Billed Charges","neg_dollar:$4.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.97","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.97","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.72","86","","","Percent of Total Billed Charges","neg_dollar:$7.72","6.28","70","","","Percent of Total Billed Charges","neg_dollar:$6.28","4.66","52","","","Percent of Total Billed Charges","neg_dollar:$4.66;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.27;102% of Medicaid interim rate","6.73","75","","","Percent of Total Billed Charges","neg_dollar:$6.73","7.72","86","","","Percent of Total Billed Charges","neg_dollar:$7.72","6.28","70","","","Percent of Total Billed Charges","neg_dollar:$6.28","5.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.11;103.5% of Medicaid interim rate","8.97","150","","","Percent of Total Billed Charges","neg_dollar:$13.87;150% of Medicaid interim rate","7.18","80","","","Percent of Total Billed Charges","neg_dollar:$7.18;Percent of Total Billed Charges","8.25","92","","","Percent of Total Billed Charges","neg_dollar:$8.25","4.66","52","","","Percent of Total Billed Charges","neg_dollar:$4.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.66","52","","","Percent of Total Billed Charges","neg_dollar:$4.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","8.00",""
"LABETALOL HCL 20 MG/4ML IV SOSY","J1920","HCPCS","00409-2339-24","NDC","636","RC","","Facility","Outpatient","4","ML","32.67","32.67","","","","32.67","Fee Schedule","","","","","32.67","Fee Schedule","101% of Medicare Fee Schedule","","","","4.00","Fee Schedule","","16.99","52","","","Percent of Total Billed Charges","neg_dollar:$16.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","32.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","32.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.10","86","","","Percent of Total Billed Charges","neg_dollar:$28.10","22.87","70","","","Percent of Total Billed Charges","neg_dollar:$22.87","16.99","52","","","Percent of Total Billed Charges","neg_dollar:$16.99;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.19;102% of Medicaid interim rate","24.50","75","","","Percent of Total Billed Charges","neg_dollar:$24.50","28.10","86","","","Percent of Total Billed Charges","neg_dollar:$28.10","22.87","70","","","Percent of Total Billed Charges","neg_dollar:$22.87","18.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.62;103.5% of Medicaid interim rate","32.67","150","","","Percent of Total Billed Charges","neg_dollar:$50.51;150% of Medicaid interim rate","26.14","80","","","Percent of Total Billed Charges","neg_dollar:$26.14;Percent of Total Billed Charges","30.06","92","","","Percent of Total Billed Charges","neg_dollar:$30.06","16.99","52","","","Percent of Total Billed Charges","neg_dollar:$16.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.99","52","","","Percent of Total Billed Charges","neg_dollar:$16.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","32.00",""
"LABETALOL HCL 20 MG/4ML IV SOSY","J1920","HCPCS","00409-2339-34","NDC","636","RC","","Facility","Outpatient","4","ML","26.42","26.42","","","","26.42","Fee Schedule","","","","","26.42","Fee Schedule","101% of Medicare Fee Schedule","","","","4.00","Fee Schedule","","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.72","86","","","Percent of Total Billed Charges","neg_dollar:$22.72","18.49","70","","","Percent of Total Billed Charges","neg_dollar:$18.49","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;105% Medicare Outpatient Cost to Charge Ratio of 52%","15.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.52;102% of Medicaid interim rate","19.81","75","","","Percent of Total Billed Charges","neg_dollar:$19.81","22.72","86","","","Percent of Total Billed Charges","neg_dollar:$22.72","18.49","70","","","Percent of Total Billed Charges","neg_dollar:$18.49","15.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.06;103.5% of Medicaid interim rate","26.42","150","","","Percent of Total Billed Charges","neg_dollar:$40.85;150% of Medicaid interim rate","21.14","80","","","Percent of Total Billed Charges","neg_dollar:$21.14;Percent of Total Billed Charges","24.31","92","","","Percent of Total Billed Charges","neg_dollar:$24.31","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","26.00",""
"LABETALOL HCL 20 MG/4ML IV SOSY","J1920","HCPCS","00409-2339-24","NDC","636","RC","","Facility","Outpatient","4","ML","48.30","48.30","","","","48.30","Fee Schedule","","","","","48.30","Fee Schedule","101% of Medicare Fee Schedule","","","","4.00","Fee Schedule","","25.11","52","","","Percent of Total Billed Charges","neg_dollar:$25.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","48.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","48.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","41.53","86","","","Percent of Total Billed Charges","neg_dollar:$41.53","33.80","70","","","Percent of Total Billed Charges","neg_dollar:$33.80","25.11","52","","","Percent of Total Billed Charges","neg_dollar:$25.11;105% Medicare Outpatient Cost to Charge Ratio of 52%","28.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.37;102% of Medicaid interim rate","36.22","75","","","Percent of Total Billed Charges","neg_dollar:$36.22","41.53","86","","","Percent of Total Billed Charges","neg_dollar:$41.53","33.80","70","","","Percent of Total Billed Charges","neg_dollar:$33.80","27.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.53;103.5% of Medicaid interim rate","48.30","150","","","Percent of Total Billed Charges","neg_dollar:$74.67;150% of Medicaid interim rate","38.64","80","","","Percent of Total Billed Charges","neg_dollar:$38.64;Percent of Total Billed Charges","44.43","92","","","Percent of Total Billed Charges","neg_dollar:$44.43","25.11","52","","","Percent of Total Billed Charges","neg_dollar:$25.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","25.11","52","","","Percent of Total Billed Charges","neg_dollar:$25.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","48.00",""
"LABETALOL HCL 5 MG/ML IV SOLN","J1920","HCPCS","00409-2267-20","NDC","636","RC","","Facility","Outpatient","1","ML","4.77","4.77","","","","4.77","Fee Schedule","","","","","4.77","Fee Schedule","101% of Medicare Fee Schedule","","","","4.00","Fee Schedule","","2.48","52","","","Percent of Total Billed Charges","neg_dollar:$2.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.10","86","","","Percent of Total Billed Charges","neg_dollar:$4.10","3.34","70","","","Percent of Total Billed Charges","neg_dollar:$3.34","2.48","52","","","Percent of Total Billed Charges","neg_dollar:$2.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.80;102% of Medicaid interim rate","3.57","75","","","Percent of Total Billed Charges","neg_dollar:$3.57","4.10","86","","","Percent of Total Billed Charges","neg_dollar:$4.10","3.34","70","","","Percent of Total Billed Charges","neg_dollar:$3.34","2.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.72;103.5% of Medicaid interim rate","4.77","150","","","Percent of Total Billed Charges","neg_dollar:$7.37;150% of Medicaid interim rate","3.81","80","","","Percent of Total Billed Charges","neg_dollar:$3.81;Percent of Total Billed Charges","4.39","92","","","Percent of Total Billed Charges","neg_dollar:$4.39","2.48","52","","","Percent of Total Billed Charges","neg_dollar:$2.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.48","52","","","Percent of Total Billed Charges","neg_dollar:$2.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1938","HCPCS","71288-203-02","NDC","250","RC","","Facility","Outpatient","1","ML","2.83","2.83","","","","2.83","Fee Schedule","","","","","2.83","Fee Schedule","","","","","2.83","Fee Schedule","","","52","","2.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.47","52","","","Percent of Total Billed Charges","neg_dollar:$1.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.47","52","","","Percent of Total Billed Charges","neg_dollar:$1.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.43","86","","","Percent of Total Billed Charges","neg_dollar:$2.43","1.98","70","","","Percent of Total Billed Charges","neg_dollar:$1.98","","52","","2.83","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.66;102% of Medicaid interim rate","2.12","75","","","Percent of Total Billed Charges","neg_dollar:$2.12","2.43","86","","","Percent of Total Billed Charges","neg_dollar:$2.43","1.98","70","","","Percent of Total Billed Charges","neg_dollar:$1.98","1.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.61;103.5% of Medicaid interim rate","2.83","150","","","Percent of Total Billed Charges","neg_dollar:$4.38;150% of Medicaid interim rate","2.26","80","","","Percent of Total Billed Charges","neg_dollar:$2.26;Percent of Total Billed Charges","2.60","92","","","Percent of Total Billed Charges","neg_dollar:$2.60","1.47","52","","","Percent of Total Billed Charges","neg_dollar:$1.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.83","Fee Schedule","","1.00","2.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1938","HCPCS","36000-283-25","NDC","250","RC","","Facility","Outpatient","1","ML","1.59","1.59","","","","1.59","Fee Schedule","","","","","1.59","Fee Schedule","","","","","1.59","Fee Schedule","","","52","","1.59","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.59","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.19","75","","","Percent of Total Billed Charges","neg_dollar:$1.19","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.59","150","","","Percent of Total Billed Charges","neg_dollar:$2.46;150% of Medicaid interim rate","1.27","80","","","Percent of Total Billed Charges","neg_dollar:$1.27;Percent of Total Billed Charges","1.46","92","","","Percent of Total Billed Charges","neg_dollar:$1.46","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.59","Fee Schedule","","1.00","1.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1938","HCPCS","71288-203-04","NDC","636","RC","","Facility","Outpatient","1","ML","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","101% of Medicare Fee Schedule","","","","1.70","Fee Schedule","","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$1;102% of Medicaid interim rate","1.28","75","","","Percent of Total Billed Charges","neg_dollar:$1.28","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.97;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.64;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.57","92","","","Percent of Total Billed Charges","neg_dollar:$1.57","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1938","HCPCS","36000-282-25","NDC","636","RC","","Facility","Outpatient","1","ML","3.02","3.02","","","","3.02","Fee Schedule","","","","","3.02","Fee Schedule","101% of Medicare Fee Schedule","","","","3.02","Fee Schedule","","1.57","52","","","Percent of Total Billed Charges","neg_dollar:$1.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.60","86","","","Percent of Total Billed Charges","neg_dollar:$2.60","2.11","70","","","Percent of Total Billed Charges","neg_dollar:$2.11","1.57","52","","","Percent of Total Billed Charges","neg_dollar:$1.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.77;102% of Medicaid interim rate","2.26","75","","","Percent of Total Billed Charges","neg_dollar:$2.26","2.60","86","","","Percent of Total Billed Charges","neg_dollar:$2.60","2.11","70","","","Percent of Total Billed Charges","neg_dollar:$2.11","1.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.72;103.5% of Medicaid interim rate","3.02","150","","","Percent of Total Billed Charges","neg_dollar:$4.67;150% of Medicaid interim rate","2.42","80","","","Percent of Total Billed Charges","neg_dollar:$2.42;Percent of Total Billed Charges","2.78","92","","","Percent of Total Billed Charges","neg_dollar:$2.78","1.57","52","","","Percent of Total Billed Charges","neg_dollar:$1.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.57","52","","","Percent of Total Billed Charges","neg_dollar:$1.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1938","HCPCS","71288-203-04","NDC","250","RC","","Facility","Outpatient","1","ML","1.81","1.81","","","","1.81","Fee Schedule","","","","","1.81","Fee Schedule","","","","","1.81","Fee Schedule","","","52","","1.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","52","","","Percent of Total Billed Charges","neg_dollar:$0.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","52","","","Percent of Total Billed Charges","neg_dollar:$0.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.56","86","","","Percent of Total Billed Charges","neg_dollar:$1.56","1.27","70","","","Percent of Total Billed Charges","neg_dollar:$1.27","","52","","1.81","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% of Medicaid interim rate","1.36","75","","","Percent of Total Billed Charges","neg_dollar:$1.36","1.56","86","","","Percent of Total Billed Charges","neg_dollar:$1.56","1.27","70","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.03;103.5% of Medicaid interim rate","1.81","150","","","Percent of Total Billed Charges","neg_dollar:$2.81;150% of Medicaid interim rate","1.45","80","","","Percent of Total Billed Charges","neg_dollar:$1.45;Percent of Total Billed Charges","1.67","92","","","Percent of Total Billed Charges","neg_dollar:$1.67","0.94","52","","","Percent of Total Billed Charges","neg_dollar:$0.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.81","Fee Schedule","","1.00","1.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1938","HCPCS","36000-283-25","NDC","636","RC","","Facility","Outpatient","1","ML","1.82","1.82","","","","1.82","Fee Schedule","","","","","1.82","Fee Schedule","101% of Medicare Fee Schedule","","","","1.82","Fee Schedule","","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.57","86","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.27","70","","","Percent of Total Billed Charges","neg_dollar:$1.27","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.07;102% of Medicaid interim rate","1.37","75","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.57","86","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.27","70","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.04;103.5% of Medicaid interim rate","1.82","150","","","Percent of Total Billed Charges","neg_dollar:$2.82;150% of Medicaid interim rate","1.46","80","","","Percent of Total Billed Charges","neg_dollar:$1.46;Percent of Total Billed Charges","1.68","92","","","Percent of Total Billed Charges","neg_dollar:$1.68","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1938","HCPCS","71288-203-02","NDC","636","RC","","Facility","Outpatient","1","ML","3.12","3.12","","","","3.12","Fee Schedule","","","","","3.12","Fee Schedule","101% of Medicare Fee Schedule","","","","3.12","Fee Schedule","","1.62","52","","","Percent of Total Billed Charges","neg_dollar:$1.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.69","86","","","Percent of Total Billed Charges","neg_dollar:$2.69","2.19","70","","","Percent of Total Billed Charges","neg_dollar:$2.19","1.62","52","","","Percent of Total Billed Charges","neg_dollar:$1.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.83;102% of Medicaid interim rate","2.34","75","","","Percent of Total Billed Charges","neg_dollar:$2.34","2.69","86","","","Percent of Total Billed Charges","neg_dollar:$2.69","2.19","70","","","Percent of Total Billed Charges","neg_dollar:$2.19","1.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.78;103.5% of Medicaid interim rate","3.12","150","","","Percent of Total Billed Charges","neg_dollar:$4.83;150% of Medicaid interim rate","2.50","80","","","Percent of Total Billed Charges","neg_dollar:$2.50;Percent of Total Billed Charges","2.87","92","","","Percent of Total Billed Charges","neg_dollar:$2.87","1.62","52","","","Percent of Total Billed Charges","neg_dollar:$1.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.62","52","","","Percent of Total Billed Charges","neg_dollar:$1.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"BUMETANIDE 0.25 MG/ML IJ SOLN","J1939","HCPCS","00641-6008-01","NDC","636","RC","","Facility","Outpatient","1","ML","24.90","24.90","","","","24.90","Fee Schedule","","","","","24.90","Fee Schedule","101% of Medicare Fee Schedule","","","","24.90","Fee Schedule","","12.94","52","","","Percent of Total Billed Charges","neg_dollar:$12.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","21.41","86","","","Percent of Total Billed Charges","neg_dollar:$21.41","17.42","70","","","Percent of Total Billed Charges","neg_dollar:$17.42","12.94","52","","","Percent of Total Billed Charges","neg_dollar:$12.94;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.62;102% of Medicaid interim rate","18.67","75","","","Percent of Total Billed Charges","neg_dollar:$18.67","21.41","86","","","Percent of Total Billed Charges","neg_dollar:$21.41","17.42","70","","","Percent of Total Billed Charges","neg_dollar:$17.42","14.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.19;103.5% of Medicaid interim rate","24.90","150","","","Percent of Total Billed Charges","neg_dollar:$38.49;150% of Medicaid interim rate","19.92","80","","","Percent of Total Billed Charges","neg_dollar:$19.92;Percent of Total Billed Charges","22.90","92","","","Percent of Total Billed Charges","neg_dollar:$22.90","12.94","52","","","Percent of Total Billed Charges","neg_dollar:$12.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.94","52","","","Percent of Total Billed Charges","neg_dollar:$12.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","24.00",""
"BUMETANIDE 0.25 MG/ML IJ SOLN","J1939","HCPCS","00641-6008-01","NDC","636","RC","","Facility","Outpatient","1","ML","17.60","17.60","","","","17.60","Fee Schedule","","","","","17.60","Fee Schedule","101% of Medicare Fee Schedule","","","","17.60","Fee Schedule","","9.15","52","","","Percent of Total Billed Charges","neg_dollar:$9.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.14","86","","","Percent of Total Billed Charges","neg_dollar:$15.14","12.32","70","","","Percent of Total Billed Charges","neg_dollar:$12.32","9.15","52","","","Percent of Total Billed Charges","neg_dollar:$9.15;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.34;102% of Medicaid interim rate","13.20","75","","","Percent of Total Billed Charges","neg_dollar:$13.20","15.14","86","","","Percent of Total Billed Charges","neg_dollar:$15.14","12.32","70","","","Percent of Total Billed Charges","neg_dollar:$12.32","10.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.03;103.5% of Medicaid interim rate","17.60","150","","","Percent of Total Billed Charges","neg_dollar:$27.22;150% of Medicaid interim rate","14.08","80","","","Percent of Total Billed Charges","neg_dollar:$14.08;Percent of Total Billed Charges","16.19","92","","","Percent of Total Billed Charges","neg_dollar:$16.19","9.15","52","","","Percent of Total Billed Charges","neg_dollar:$9.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.15","52","","","Percent of Total Billed Charges","neg_dollar:$9.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","17.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","36000-283-25","NDC","250","RC","","Facility","Outpatient","1","ML","23.07","23.07","","","","23.07","Fee Schedule","","","","","23.07","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","23.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.99","52","","","Percent of Total Billed Charges","neg_dollar:$11.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.99","52","","","Percent of Total Billed Charges","neg_dollar:$11.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.84","86","","","Percent of Total Billed Charges","neg_dollar:$19.84","16.15","70","","","Percent of Total Billed Charges","neg_dollar:$16.15","","52","","23.07","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.55;102% of Medicaid interim rate","17.30","75","","","Percent of Total Billed Charges","neg_dollar:$17.30","19.84","86","","","Percent of Total Billed Charges","neg_dollar:$19.84","16.15","70","","","Percent of Total Billed Charges","neg_dollar:$16.15","13.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.15;103.5% of Medicaid interim rate","23.07","150","","","Percent of Total Billed Charges","neg_dollar:$35.67;150% of Medicaid interim rate","18.45","80","","","Percent of Total Billed Charges","neg_dollar:$18.45;Percent of Total Billed Charges","21.22","92","","","Percent of Total Billed Charges","neg_dollar:$21.22","11.99","52","","","Percent of Total Billed Charges","neg_dollar:$11.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","23.07","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","23.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","36000-282-25","NDC","636","RC","","Facility","Outpatient","1","ML","28.01","28.01","","","","28.01","Fee Schedule","","","","","28.01","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","28.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","28.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","24.09","86","","","Percent of Total Billed Charges","neg_dollar:$24.09","19.61","70","","","Percent of Total Billed Charges","neg_dollar:$19.61","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.45;102% of Medicaid interim rate","21.01","75","","","Percent of Total Billed Charges","neg_dollar:$21.01","24.09","86","","","Percent of Total Billed Charges","neg_dollar:$24.09","19.61","70","","","Percent of Total Billed Charges","neg_dollar:$19.61","15.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.96;103.5% of Medicaid interim rate","28.01","150","","","Percent of Total Billed Charges","neg_dollar:$43.31;150% of Medicaid interim rate","22.41","80","","","Percent of Total Billed Charges","neg_dollar:$22.41;Percent of Total Billed Charges","25.77","92","","","Percent of Total Billed Charges","neg_dollar:$25.77","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","28.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","36000-282-25","NDC","636","RC","","Facility","Outpatient","1","ML","39.67","39.67","","","","34.00","Fee Schedule","","","","","39.67","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","20.62","52","","","Percent of Total Billed Charges","neg_dollar:$20.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","39.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","39.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","34.11","86","","","Percent of Total Billed Charges","neg_dollar:$34.11","27.76","70","","","Percent of Total Billed Charges","neg_dollar:$27.76","20.62","52","","","Percent of Total Billed Charges","neg_dollar:$20.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","23.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$23.30;102% of Medicaid interim rate","29.75","75","","","Percent of Total Billed Charges","neg_dollar:$29.75","34.11","86","","","Percent of Total Billed Charges","neg_dollar:$34.11","27.76","70","","","Percent of Total Billed Charges","neg_dollar:$27.76","22.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.61;103.5% of Medicaid interim rate","39.67","150","","","Percent of Total Billed Charges","neg_dollar:$61.33;150% of Medicaid interim rate","31.73","80","","","Percent of Total Billed Charges","neg_dollar:$31.73;Percent of Total Billed Charges","36.49","92","","","Percent of Total Billed Charges","neg_dollar:$36.49","20.62","52","","","Percent of Total Billed Charges","neg_dollar:$20.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","20.62","52","","","Percent of Total Billed Charges","neg_dollar:$20.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","39.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","71288-203-02","NDC","250","RC","","Facility","Outpatient","1","ML","28.01","28.01","","","","28.01","Fee Schedule","","","","","28.01","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","28.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.09","86","","","Percent of Total Billed Charges","neg_dollar:$24.09","19.60","70","","","Percent of Total Billed Charges","neg_dollar:$19.60","","52","","28.01","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","16.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.45;102% of Medicaid interim rate","21.01","75","","","Percent of Total Billed Charges","neg_dollar:$21.01","24.09","86","","","Percent of Total Billed Charges","neg_dollar:$24.09","19.60","70","","","Percent of Total Billed Charges","neg_dollar:$19.60","15.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.96;103.5% of Medicaid interim rate","28.01","150","","","Percent of Total Billed Charges","neg_dollar:$43.31;150% of Medicaid interim rate","22.41","80","","","Percent of Total Billed Charges","neg_dollar:$22.41;Percent of Total Billed Charges","25.77","92","","","Percent of Total Billed Charges","neg_dollar:$25.77","14.56","52","","","Percent of Total Billed Charges","neg_dollar:$14.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","28.01","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","28.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","71288-203-05","NDC","250","RC","","Facility","Outpatient","1","ML","45.12","45.12","","","","34.00","Fee Schedule","","","","","45.12","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","45.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","23.46","52","","","Percent of Total Billed Charges","neg_dollar:$23.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.46","52","","","Percent of Total Billed Charges","neg_dollar:$23.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","38.80","86","","","Percent of Total Billed Charges","neg_dollar:$38.80","31.58","70","","","Percent of Total Billed Charges","neg_dollar:$31.58","","52","","45.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","26.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.51;102% of Medicaid interim rate","33.84","75","","","Percent of Total Billed Charges","neg_dollar:$33.84","38.80","86","","","Percent of Total Billed Charges","neg_dollar:$38.80","31.58","70","","","Percent of Total Billed Charges","neg_dollar:$31.58","25.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.72;103.5% of Medicaid interim rate","45.12","150","","","Percent of Total Billed Charges","neg_dollar:$69.76;150% of Medicaid interim rate","36.10","80","","","Percent of Total Billed Charges","neg_dollar:$36.10;Percent of Total Billed Charges","41.51","92","","","Percent of Total Billed Charges","neg_dollar:$41.51","23.46","52","","","Percent of Total Billed Charges","neg_dollar:$23.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","45.12","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","45.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","36000-283-25","NDC","250","RC","","Facility","Outpatient","1","ML","36.99","36.99","","","","34.00","Fee Schedule","","","","","36.99","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","36.99","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","19.23","52","","","Percent of Total Billed Charges","neg_dollar:$19.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.23","52","","","Percent of Total Billed Charges","neg_dollar:$19.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.81","86","","","Percent of Total Billed Charges","neg_dollar:$31.81","25.89","70","","","Percent of Total Billed Charges","neg_dollar:$25.89","","52","","36.99","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","21.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.73;102% of Medicaid interim rate","27.74","75","","","Percent of Total Billed Charges","neg_dollar:$27.74","31.81","86","","","Percent of Total Billed Charges","neg_dollar:$31.81","25.89","70","","","Percent of Total Billed Charges","neg_dollar:$25.89","21.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.08;103.5% of Medicaid interim rate","36.99","150","","","Percent of Total Billed Charges","neg_dollar:$57.19;150% of Medicaid interim rate","29.59","80","","","Percent of Total Billed Charges","neg_dollar:$29.59;Percent of Total Billed Charges","34.03","92","","","Percent of Total Billed Charges","neg_dollar:$34.03","19.23","52","","","Percent of Total Billed Charges","neg_dollar:$19.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","36.99","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","36.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","36000-283-25","NDC","636","RC","","Facility","Outpatient","1","ML","36.61","36.61","","","","34.00","Fee Schedule","","","","","36.61","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","19.03","52","","","Percent of Total Billed Charges","neg_dollar:$19.03;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","36.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","36.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.48","86","","","Percent of Total Billed Charges","neg_dollar:$31.48","25.62","70","","","Percent of Total Billed Charges","neg_dollar:$25.62","19.03","52","","","Percent of Total Billed Charges","neg_dollar:$19.03;105% Medicare Outpatient Cost to Charge Ratio of 52%","21.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.50;102% of Medicaid interim rate","27.45","75","","","Percent of Total Billed Charges","neg_dollar:$27.45","31.48","86","","","Percent of Total Billed Charges","neg_dollar:$31.48","25.62","70","","","Percent of Total Billed Charges","neg_dollar:$25.62","20.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.86;103.5% of Medicaid interim rate","36.61","150","","","Percent of Total Billed Charges","neg_dollar:$56.60;150% of Medicaid interim rate","29.28","80","","","Percent of Total Billed Charges","neg_dollar:$29.28;Percent of Total Billed Charges","33.68","92","","","Percent of Total Billed Charges","neg_dollar:$33.68","19.03","52","","","Percent of Total Billed Charges","neg_dollar:$19.03;100% Medicare Outpatient Cost to Charge Ratio of 52%","19.03","52","","","Percent of Total Billed Charges","neg_dollar:$19.03;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","36.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","71288-203-02","NDC","636","RC","","Facility","Outpatient","1","ML","40.28","40.28","","","","34.00","Fee Schedule","","","","","40.28","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","20.94","52","","","Percent of Total Billed Charges","neg_dollar:$20.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","40.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","40.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","34.64","86","","","Percent of Total Billed Charges","neg_dollar:$34.64","28.19","70","","","Percent of Total Billed Charges","neg_dollar:$28.19","20.94","52","","","Percent of Total Billed Charges","neg_dollar:$20.94;105% Medicare Outpatient Cost to Charge Ratio of 52%","23.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$23.66;102% of Medicaid interim rate","30.21","75","","","Percent of Total Billed Charges","neg_dollar:$30.21","34.64","86","","","Percent of Total Billed Charges","neg_dollar:$34.64","28.19","70","","","Percent of Total Billed Charges","neg_dollar:$28.19","22.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.96;103.5% of Medicaid interim rate","40.28","150","","","Percent of Total Billed Charges","neg_dollar:$62.27;150% of Medicaid interim rate","32.22","80","","","Percent of Total Billed Charges","neg_dollar:$32.22;Percent of Total Billed Charges","37.05","92","","","Percent of Total Billed Charges","neg_dollar:$37.05","20.94","52","","","Percent of Total Billed Charges","neg_dollar:$20.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","20.94","52","","","Percent of Total Billed Charges","neg_dollar:$20.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","40.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","36000-283-25","NDC","636","RC","","Facility","Outpatient","1","ML","31.13","31.13","","","","31.13","Fee Schedule","","","","","31.13","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","16.18","52","","","Percent of Total Billed Charges","neg_dollar:$16.18;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","26.77","86","","","Percent of Total Billed Charges","neg_dollar:$26.77","21.79","70","","","Percent of Total Billed Charges","neg_dollar:$21.79","16.18","52","","","Percent of Total Billed Charges","neg_dollar:$16.18;105% Medicare Outpatient Cost to Charge Ratio of 52%","18.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.29;102% of Medicaid interim rate","23.35","75","","","Percent of Total Billed Charges","neg_dollar:$23.35","26.77","86","","","Percent of Total Billed Charges","neg_dollar:$26.77","21.79","70","","","Percent of Total Billed Charges","neg_dollar:$21.79","17.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.74;103.5% of Medicaid interim rate","31.13","150","","","Percent of Total Billed Charges","neg_dollar:$48.13;150% of Medicaid interim rate","24.90","80","","","Percent of Total Billed Charges","neg_dollar:$24.90;Percent of Total Billed Charges","28.64","92","","","Percent of Total Billed Charges","neg_dollar:$28.64","16.18","52","","","Percent of Total Billed Charges","neg_dollar:$16.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.18","52","","","Percent of Total Billed Charges","neg_dollar:$16.18;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","31.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","71288-203-02","NDC","636","RC","","Facility","Outpatient","1","ML","42.20","42.20","","","","34.00","Fee Schedule","","","","","42.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","21.94","52","","","Percent of Total Billed Charges","neg_dollar:$21.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","42.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","42.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","36.29","86","","","Percent of Total Billed Charges","neg_dollar:$36.29","29.54","70","","","Percent of Total Billed Charges","neg_dollar:$29.54","21.94","52","","","Percent of Total Billed Charges","neg_dollar:$21.94;105% Medicare Outpatient Cost to Charge Ratio of 52%","24.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.79;102% of Medicaid interim rate","31.65","75","","","Percent of Total Billed Charges","neg_dollar:$31.65","36.29","86","","","Percent of Total Billed Charges","neg_dollar:$36.29","29.54","70","","","Percent of Total Billed Charges","neg_dollar:$29.54","24.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.05;103.5% of Medicaid interim rate","42.20","150","","","Percent of Total Billed Charges","neg_dollar:$65.24;150% of Medicaid interim rate","33.76","80","","","Percent of Total Billed Charges","neg_dollar:$33.76;Percent of Total Billed Charges","38.82","92","","","Percent of Total Billed Charges","neg_dollar:$38.82","21.94","52","","","Percent of Total Billed Charges","neg_dollar:$21.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","21.94","52","","","Percent of Total Billed Charges","neg_dollar:$21.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","42.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","71288-203-02","NDC","250","RC","","Facility","Outpatient","1","ML","43.66","43.66","","","","34.00","Fee Schedule","","","","","43.66","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","43.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.70","52","","","Percent of Total Billed Charges","neg_dollar:$22.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","22.70","52","","","Percent of Total Billed Charges","neg_dollar:$22.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","37.55","86","","","Percent of Total Billed Charges","neg_dollar:$37.55","30.56","70","","","Percent of Total Billed Charges","neg_dollar:$30.56","","52","","43.66","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","25.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.65;102% of Medicaid interim rate","32.74","75","","","Percent of Total Billed Charges","neg_dollar:$32.74","37.55","86","","","Percent of Total Billed Charges","neg_dollar:$37.55","30.56","70","","","Percent of Total Billed Charges","neg_dollar:$30.56","24.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.88;103.5% of Medicaid interim rate","43.66","150","","","Percent of Total Billed Charges","neg_dollar:$67.51;150% of Medicaid interim rate","34.93","80","","","Percent of Total Billed Charges","neg_dollar:$34.93;Percent of Total Billed Charges","40.17","92","","","Percent of Total Billed Charges","neg_dollar:$40.17","22.70","52","","","Percent of Total Billed Charges","neg_dollar:$22.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","43.66","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","43.00",""
"FUROSEMIDE 10 MG/ML IJ SOLN","J1940","HCPCS","36000-282-25","NDC","250","RC","","Facility","Outpatient","1","ML","24.96","24.96","","","","24.96","Fee Schedule","","","","","24.96","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","24.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.98","52","","","Percent of Total Billed Charges","neg_dollar:$12.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.98","52","","","Percent of Total Billed Charges","neg_dollar:$12.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.46","86","","","Percent of Total Billed Charges","neg_dollar:$21.46","17.47","70","","","Percent of Total Billed Charges","neg_dollar:$17.47","","52","","24.96","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.66;102% of Medicaid interim rate","18.72","75","","","Percent of Total Billed Charges","neg_dollar:$18.72","21.46","86","","","Percent of Total Billed Charges","neg_dollar:$21.46","17.47","70","","","Percent of Total Billed Charges","neg_dollar:$17.47","14.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.22;103.5% of Medicaid interim rate","24.96","150","","","Percent of Total Billed Charges","neg_dollar:$38.59;150% of Medicaid interim rate","19.97","80","","","Percent of Total Billed Charges","neg_dollar:$19.97;Percent of Total Billed Charges","22.96","92","","","Percent of Total Billed Charges","neg_dollar:$22.96","12.98","52","","","Percent of Total Billed Charges","neg_dollar:$12.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","24.96","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","24.00",""
"LEVETIRACETAM 500 MG/5ML IV SOLN","J1953","HCPCS","67457-790-00","NDC","250","RC","","Facility","Outpatient","5","ML","2.06","2.06","","","","2.06","Fee Schedule","","","","","2.06","Fee Schedule","","","","","2.06","Fee Schedule","","","52","","2.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.77","86","","","Percent of Total Billed Charges","neg_dollar:$1.77","1.44","70","","","Percent of Total Billed Charges","neg_dollar:$1.44","","52","","2.06","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.21;102% of Medicaid interim rate","1.54","75","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.77","86","","","Percent of Total Billed Charges","neg_dollar:$1.77","1.44","70","","","Percent of Total Billed Charges","neg_dollar:$1.44","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;103.5% of Medicaid interim rate","2.06","150","","","Percent of Total Billed Charges","neg_dollar:$3.18;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.89","92","","","Percent of Total Billed Charges","neg_dollar:$1.89","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.06","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"LEVETIRACETAM 500 MG/5ML IV SOLN","J1953","HCPCS","67457-790-05","NDC","250","RC","","Facility","Outpatient","5","ML","2.17","2.17","","","","2.17","Fee Schedule","","","","","2.17","Fee Schedule","","","","","2.17","Fee Schedule","","","52","","2.17","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.12","52","","","Percent of Total Billed Charges","neg_dollar:$1.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.12","52","","","Percent of Total Billed Charges","neg_dollar:$1.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.86","86","","","Percent of Total Billed Charges","neg_dollar:$1.86","1.51","70","","","Percent of Total Billed Charges","neg_dollar:$1.51","","52","","2.17","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.27;102% of Medicaid interim rate","1.62","75","","","Percent of Total Billed Charges","neg_dollar:$1.62","1.86","86","","","Percent of Total Billed Charges","neg_dollar:$1.86","1.51","70","","","Percent of Total Billed Charges","neg_dollar:$1.51","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;103.5% of Medicaid interim rate","2.17","150","","","Percent of Total Billed Charges","neg_dollar:$3.35;150% of Medicaid interim rate","1.73","80","","","Percent of Total Billed Charges","neg_dollar:$1.73;Percent of Total Billed Charges","1.99","92","","","Percent of Total Billed Charges","neg_dollar:$1.99","1.12","52","","","Percent of Total Billed Charges","neg_dollar:$1.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.17","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"LEVETIRACETAM 500 MG/5ML IV SOLN","J1953","HCPCS","67457-790-00","NDC","636","RC","","Facility","Outpatient","5","ML","1.58","1.58","","","","1.58","Fee Schedule","","","","","1.58","Fee Schedule","101% of Medicare Fee Schedule","","","","1.58","Fee Schedule","","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.36","86","","","Percent of Total Billed Charges","neg_dollar:$1.36","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.18","75","","","Percent of Total Billed Charges","neg_dollar:$1.18","1.36","86","","","Percent of Total Billed Charges","neg_dollar:$1.36","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.90;103.5% of Medicaid interim rate","1.58","150","","","Percent of Total Billed Charges","neg_dollar:$2.45;150% of Medicaid interim rate","1.26","80","","","Percent of Total Billed Charges","neg_dollar:$1.26;Percent of Total Billed Charges","1.45","92","","","Percent of Total Billed Charges","neg_dollar:$1.45","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LEVETIRACETAM 500 MG/5ML IV SOLN","J1953","HCPCS","67457-790-05","NDC","636","RC","","Facility","Outpatient","5","ML","1.29","1.29","","","","1.29","Fee Schedule","","","","","1.29","Fee Schedule","101% of Medicare Fee Schedule","","","","1.29","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.29","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.29","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;103.5% of Medicaid interim rate","1.29","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.03","80","","","Percent of Total Billed Charges","neg_dollar:$1.03;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LEVETIRACETAM 500 MG/5ML IV SOLN","J1953","HCPCS","67457-790-00","NDC","636","RC","","Facility","Outpatient","5","ML","1.21","1.21","","","","1.21","Fee Schedule","","","","","1.21","Fee Schedule","101% of Medicare Fee Schedule","","","","1.21","Fee Schedule","","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","86","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% of Medicaid interim rate","0.91","75","","","Percent of Total Billed Charges","neg_dollar:$0.91","1.04","86","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;103.5% of Medicaid interim rate","1.21","150","","","Percent of Total Billed Charges","neg_dollar:$1.87;150% of Medicaid interim rate","0.97","80","","","Percent of Total Billed Charges","neg_dollar:$0.97;Percent of Total Billed Charges","1.11","92","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LEVETIRACETAM 500 MG/5ML IV SOLN","J1953","HCPCS","63323-400-05","NDC","636","RC","","Facility","Outpatient","5","ML","2.06","2.06","","","","2.06","Fee Schedule","","","","","2.06","Fee Schedule","101% of Medicare Fee Schedule","","","","2.06","Fee Schedule","","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.77","86","","","Percent of Total Billed Charges","neg_dollar:$1.77","1.44","70","","","Percent of Total Billed Charges","neg_dollar:$1.44","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.21;102% of Medicaid interim rate","1.54","75","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.77","86","","","Percent of Total Billed Charges","neg_dollar:$1.77","1.44","70","","","Percent of Total Billed Charges","neg_dollar:$1.44","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;103.5% of Medicaid interim rate","2.06","150","","","Percent of Total Billed Charges","neg_dollar:$3.19;150% of Medicaid interim rate","1.65","80","","","Percent of Total Billed Charges","neg_dollar:$1.65;Percent of Total Billed Charges","1.90","92","","","Percent of Total Billed Charges","neg_dollar:$1.90","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN","J1956","HCPCS","44567-435-24","NDC","250","RC","","Facility","Outpatient","50","ML","101.90","101.90","","","","37.00","Fee Schedule","","","","","51.00","Fee Schedule","","","","","39.00","Fee Schedule","","","52","","101.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","52.98","52","","","Percent of Total Billed Charges","neg_dollar:$52.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.98","52","","","Percent of Total Billed Charges","neg_dollar:$52.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","87.63","86","","","Percent of Total Billed Charges","neg_dollar:$87.63","71.33","70","","","Percent of Total Billed Charges","neg_dollar:$71.33","","52","","80.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","59.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.86;102% of Medicaid interim rate","76.42","75","","","Percent of Total Billed Charges","neg_dollar:$76.42","87.63","86","","","Percent of Total Billed Charges","neg_dollar:$87.63","71.33","70","","","Percent of Total Billed Charges","neg_dollar:$71.33","58.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$58.08;103.5% of Medicaid interim rate","101.90","150","","","Percent of Total Billed Charges","neg_dollar:$157.54;150% of Medicaid interim rate","81.52","80","","","Percent of Total Billed Charges","neg_dollar:$81.52;Percent of Total Billed Charges","93.74","92","","","Percent of Total Billed Charges","neg_dollar:$93.74","52.98","52","","","Percent of Total Billed Charges","neg_dollar:$52.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","61.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","37.00","101.00",""
"LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN","J1956","HCPCS","25021-132-82","NDC","250","RC","","Facility","Outpatient","100","ML","54.75","54.75","","","","37.00","Fee Schedule","","","","","51.00","Fee Schedule","","","","","39.00","Fee Schedule","","","52","","54.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.47","52","","","Percent of Total Billed Charges","neg_dollar:$28.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.47","52","","","Percent of Total Billed Charges","neg_dollar:$28.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.08","86","","","Percent of Total Billed Charges","neg_dollar:$47.08","38.32","70","","","Percent of Total Billed Charges","neg_dollar:$38.32","","52","","54.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","32.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.16;102% of Medicaid interim rate","41.06","75","","","Percent of Total Billed Charges","neg_dollar:$41.06","47.08","86","","","Percent of Total Billed Charges","neg_dollar:$47.08","38.32","70","","","Percent of Total Billed Charges","neg_dollar:$38.32","31.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.20;103.5% of Medicaid interim rate","54.75","150","","","Percent of Total Billed Charges","neg_dollar:$84.64;150% of Medicaid interim rate","43.80","80","","","Percent of Total Billed Charges","neg_dollar:$43.80;Percent of Total Billed Charges","50.37","92","","","Percent of Total Billed Charges","neg_dollar:$50.37","28.47","52","","","Percent of Total Billed Charges","neg_dollar:$28.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.75","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","28.00","54.00",""
"LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN","J1956","HCPCS","36000-047-24","NDC","250","RC","","Facility","Outpatient","100","ML","2.50","2.50","","","","2.50","Fee Schedule","","","","","2.50","Fee Schedule","","","","","2.50","Fee Schedule","","","52","","2.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.15","86","","","Percent of Total Billed Charges","neg_dollar:$2.15","1.75","70","","","Percent of Total Billed Charges","neg_dollar:$1.75","","52","","2.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.46;102% of Medicaid interim rate","1.87","75","","","Percent of Total Billed Charges","neg_dollar:$1.87","2.15","86","","","Percent of Total Billed Charges","neg_dollar:$2.15","1.75","70","","","Percent of Total Billed Charges","neg_dollar:$1.75","1.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.42;103.5% of Medicaid interim rate","2.50","150","","","Percent of Total Billed Charges","neg_dollar:$3.86;150% of Medicaid interim rate","2.00","80","","","Percent of Total Billed Charges","neg_dollar:$2;Percent of Total Billed Charges","2.30","92","","","Percent of Total Billed Charges","neg_dollar:$2.30","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.50","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN","J1956","HCPCS","25021-132-82","NDC","636","RC","","Facility","Outpatient","100","ML","53.01","53.01","","","","37.00","Fee Schedule","","","","","51.00","Fee Schedule","101% of Medicare Fee Schedule","","","","39.00","Fee Schedule","","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","53.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","53.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.59","86","","","Percent of Total Billed Charges","neg_dollar:$45.59","37.11","70","","","Percent of Total Billed Charges","neg_dollar:$37.11","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","31.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.14;102% of Medicaid interim rate","39.76","75","","","Percent of Total Billed Charges","neg_dollar:$39.76","45.59","86","","","Percent of Total Billed Charges","neg_dollar:$45.59","37.11","70","","","Percent of Total Billed Charges","neg_dollar:$37.11","30.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.21;103.5% of Medicaid interim rate","53.01","150","","","Percent of Total Billed Charges","neg_dollar:$81.96;150% of Medicaid interim rate","42.41","80","","","Percent of Total Billed Charges","neg_dollar:$42.41;Percent of Total Billed Charges","48.77","92","","","Percent of Total Billed Charges","neg_dollar:$48.77","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.00","53.00",""
"LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN","J1956","HCPCS","36000-047-24","NDC","636","RC","","Facility","Outpatient","100","ML","48.75","48.75","","","","37.00","Fee Schedule","","","","","48.75","Fee Schedule","101% of Medicare Fee Schedule","","","","39.00","Fee Schedule","","25.35","52","","","Percent of Total Billed Charges","neg_dollar:$25.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","48.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","48.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","41.92","86","","","Percent of Total Billed Charges","neg_dollar:$41.92","34.12","70","","","Percent of Total Billed Charges","neg_dollar:$34.12","25.35","52","","","Percent of Total Billed Charges","neg_dollar:$25.35;105% Medicare Outpatient Cost to Charge Ratio of 52%","28.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.64;102% of Medicaid interim rate","36.56","75","","","Percent of Total Billed Charges","neg_dollar:$36.56","41.92","86","","","Percent of Total Billed Charges","neg_dollar:$41.92","34.12","70","","","Percent of Total Billed Charges","neg_dollar:$34.12","27.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.78;103.5% of Medicaid interim rate","48.75","150","","","Percent of Total Billed Charges","neg_dollar:$75.36;150% of Medicaid interim rate","39.00","80","","","Percent of Total Billed Charges","neg_dollar:$39;Percent of Total Billed Charges","44.85","92","","","Percent of Total Billed Charges","neg_dollar:$44.85","25.35","52","","","Percent of Total Billed Charges","neg_dollar:$25.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","25.35","52","","","Percent of Total Billed Charges","neg_dollar:$25.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","25.00","48.00",""
"LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN","J1956","HCPCS","25021-132-82","NDC","250","RC","","Facility","Outpatient","100","ML","98.50","98.50","","","","37.00","Fee Schedule","","","","","51.00","Fee Schedule","","","","","39.00","Fee Schedule","","","52","","98.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","51.22","52","","","Percent of Total Billed Charges","neg_dollar:$51.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.22","52","","","Percent of Total Billed Charges","neg_dollar:$51.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","84.71","86","","","Percent of Total Billed Charges","neg_dollar:$84.71","68.94","70","","","Percent of Total Billed Charges","neg_dollar:$68.94","","52","","80.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","57.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.86;102% of Medicaid interim rate","73.87","75","","","Percent of Total Billed Charges","neg_dollar:$73.87","84.71","86","","","Percent of Total Billed Charges","neg_dollar:$84.71","68.94","70","","","Percent of Total Billed Charges","neg_dollar:$68.94","56.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.14;103.5% of Medicaid interim rate","98.50","150","","","Percent of Total Billed Charges","neg_dollar:$152.28;150% of Medicaid interim rate","78.80","80","","","Percent of Total Billed Charges","neg_dollar:$78.80;Percent of Total Billed Charges","90.62","92","","","Percent of Total Billed Charges","neg_dollar:$90.62","51.22","52","","","Percent of Total Billed Charges","neg_dollar:$51.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","61.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","37.00","98.00",""
"LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN","J1956","HCPCS","36000-047-24","NDC","250","RC","","Facility","Outpatient","100","ML","57.50","57.50","","","","37.00","Fee Schedule","","","","","51.00","Fee Schedule","","","","","39.00","Fee Schedule","","","52","","57.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","29.90","52","","","Percent of Total Billed Charges","neg_dollar:$29.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","29.90","52","","","Percent of Total Billed Charges","neg_dollar:$29.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","49.44","86","","","Percent of Total Billed Charges","neg_dollar:$49.44","40.25","70","","","Percent of Total Billed Charges","neg_dollar:$40.25","","52","","57.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","33.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.78;102% of Medicaid interim rate","43.12","75","","","Percent of Total Billed Charges","neg_dollar:$43.12","49.44","86","","","Percent of Total Billed Charges","neg_dollar:$49.44","40.25","70","","","Percent of Total Billed Charges","neg_dollar:$40.25","32.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.77;103.5% of Medicaid interim rate","57.50","150","","","Percent of Total Billed Charges","neg_dollar:$88.89;150% of Medicaid interim rate","46.00","80","","","Percent of Total Billed Charges","neg_dollar:$46;Percent of Total Billed Charges","52.90","92","","","Percent of Total Billed Charges","neg_dollar:$52.90","29.90","52","","","Percent of Total Billed Charges","neg_dollar:$29.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","57.50","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","29.00","57.00",""
"LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN","J1956","HCPCS","44567-437-24","NDC","636","RC","","Facility","Outpatient","150","ML","37.86","37.86","","","","37.00","Fee Schedule","","","","","37.86","Fee Schedule","101% of Medicare Fee Schedule","","","","37.86","Fee Schedule","","19.69","52","","","Percent of Total Billed Charges","neg_dollar:$19.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","37.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","37.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","32.56","86","","","Percent of Total Billed Charges","neg_dollar:$32.56","26.50","70","","","Percent of Total Billed Charges","neg_dollar:$26.50","19.69","52","","","Percent of Total Billed Charges","neg_dollar:$19.69;105% Medicare Outpatient Cost to Charge Ratio of 52%","22.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.24;102% of Medicaid interim rate","28.39","75","","","Percent of Total Billed Charges","neg_dollar:$28.39","32.56","86","","","Percent of Total Billed Charges","neg_dollar:$32.56","26.50","70","","","Percent of Total Billed Charges","neg_dollar:$26.50","21.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.58;103.5% of Medicaid interim rate","37.86","150","","","Percent of Total Billed Charges","neg_dollar:$58.54;150% of Medicaid interim rate","30.29","80","","","Percent of Total Billed Charges","neg_dollar:$30.29;Percent of Total Billed Charges","34.83","92","","","Percent of Total Billed Charges","neg_dollar:$34.83","19.69","52","","","Percent of Total Billed Charges","neg_dollar:$19.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","19.69","52","","","Percent of Total Billed Charges","neg_dollar:$19.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","19.00","37.00",""
"LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN","J1956","HCPCS","00143-9720-01","NDC","250","RC","","Facility","Outpatient","150","ML","33.36","33.36","","","","33.36","Fee Schedule","","","","","33.36","Fee Schedule","","","","","33.36","Fee Schedule","","","52","","33.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.69","86","","","Percent of Total Billed Charges","neg_dollar:$28.69","23.35","70","","","Percent of Total Billed Charges","neg_dollar:$23.35","","52","","33.36","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","19.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.60;102% of Medicaid interim rate","25.02","75","","","Percent of Total Billed Charges","neg_dollar:$25.02","28.69","86","","","Percent of Total Billed Charges","neg_dollar:$28.69","23.35","70","","","Percent of Total Billed Charges","neg_dollar:$23.35","19.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.01;103.5% of Medicaid interim rate","33.36","150","","","Percent of Total Billed Charges","neg_dollar:$51.58;150% of Medicaid interim rate","26.69","80","","","Percent of Total Billed Charges","neg_dollar:$26.69;Percent of Total Billed Charges","30.69","92","","","Percent of Total Billed Charges","neg_dollar:$30.69","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","33.36","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","33.00",""
"LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN","J1956","HCPCS","44567-437-24","NDC","250","RC","","Facility","Outpatient","150","ML","37.86","37.86","","","","37.00","Fee Schedule","","","","","37.86","Fee Schedule","","","","","37.86","Fee Schedule","","","52","","37.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","19.69","52","","","Percent of Total Billed Charges","neg_dollar:$19.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.69","52","","","Percent of Total Billed Charges","neg_dollar:$19.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.56","86","","","Percent of Total Billed Charges","neg_dollar:$32.56","26.50","70","","","Percent of Total Billed Charges","neg_dollar:$26.50","","52","","37.86","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","22.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.24;102% of Medicaid interim rate","28.39","75","","","Percent of Total Billed Charges","neg_dollar:$28.39","32.56","86","","","Percent of Total Billed Charges","neg_dollar:$32.56","26.50","70","","","Percent of Total Billed Charges","neg_dollar:$26.50","21.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.58;103.5% of Medicaid interim rate","37.86","150","","","Percent of Total Billed Charges","neg_dollar:$58.54;150% of Medicaid interim rate","30.29","80","","","Percent of Total Billed Charges","neg_dollar:$30.29;Percent of Total Billed Charges","34.83","92","","","Percent of Total Billed Charges","neg_dollar:$34.83","19.69","52","","","Percent of Total Billed Charges","neg_dollar:$19.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","37.86","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","19.00","37.00",""
"LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN","J1956","HCPCS","00143-9720-01","NDC","636","RC","","Facility","Outpatient","150","ML","33.36","33.36","","","","33.36","Fee Schedule","","","","","33.36","Fee Schedule","101% of Medicare Fee Schedule","","","","33.36","Fee Schedule","","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","33.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","33.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.69","86","","","Percent of Total Billed Charges","neg_dollar:$28.69","23.35","70","","","Percent of Total Billed Charges","neg_dollar:$23.35","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.60;102% of Medicaid interim rate","25.02","75","","","Percent of Total Billed Charges","neg_dollar:$25.02","28.69","86","","","Percent of Total Billed Charges","neg_dollar:$28.69","23.35","70","","","Percent of Total Billed Charges","neg_dollar:$23.35","19.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.01;103.5% of Medicaid interim rate","33.36","150","","","Percent of Total Billed Charges","neg_dollar:$51.58;150% of Medicaid interim rate","26.69","80","","","Percent of Total Billed Charges","neg_dollar:$26.69;Percent of Total Billed Charges","30.69","92","","","Percent of Total Billed Charges","neg_dollar:$30.69","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","33.00",""
"LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN","J1956","HCPCS","00143-9720-24","NDC","636","RC","","Facility","Outpatient","150","ML","33.36","33.36","","","","33.36","Fee Schedule","","","","","33.36","Fee Schedule","101% of Medicare Fee Schedule","","","","33.36","Fee Schedule","","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","33.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","33.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.69","86","","","Percent of Total Billed Charges","neg_dollar:$28.69","23.35","70","","","Percent of Total Billed Charges","neg_dollar:$23.35","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.60;102% of Medicaid interim rate","25.02","75","","","Percent of Total Billed Charges","neg_dollar:$25.02","28.69","86","","","Percent of Total Billed Charges","neg_dollar:$28.69","23.35","70","","","Percent of Total Billed Charges","neg_dollar:$23.35","19.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.01;103.5% of Medicaid interim rate","33.36","150","","","Percent of Total Billed Charges","neg_dollar:$51.58;150% of Medicaid interim rate","26.69","80","","","Percent of Total Billed Charges","neg_dollar:$26.69;Percent of Total Billed Charges","30.69","92","","","Percent of Total Billed Charges","neg_dollar:$30.69","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.35","52","","","Percent of Total Billed Charges","neg_dollar:$17.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.00","33.00",""
"LIDOCAINE HCL (CARDIAC) 100 MG/5ML IV SOSY","J2001","HCPCS","00409-4903-11","NDC","250","RC","","Facility","Outpatient","5","ML","10","10.00","","","","10.00","Fee Schedule","","","","","10.00","Fee Schedule","","","","","10.00","Fee Schedule","","","52","","10.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.20","52","","","Percent of Total Billed Charges","neg_dollar:$5.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.20","52","","","Percent of Total Billed Charges","neg_dollar:$5.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.60","86","","","Percent of Total Billed Charges","neg_dollar:$8.60","7.00","70","","","Percent of Total Billed Charges","neg_dollar:$7","","52","","10.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.87;102% of Medicaid interim rate","7.50","75","","","Percent of Total Billed Charges","neg_dollar:$7.50","8.60","86","","","Percent of Total Billed Charges","neg_dollar:$8.60","7.00","70","","","Percent of Total Billed Charges","neg_dollar:$7","5.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.70;103.5% of Medicaid interim rate","10.00","150","","","Percent of Total Billed Charges","neg_dollar:$15.46;150% of Medicaid interim rate","8.00","80","","","Percent of Total Billed Charges","neg_dollar:$8;Percent of Total Billed Charges","9.20","92","","","Percent of Total Billed Charges","neg_dollar:$9.20","5.20","52","","","Percent of Total Billed Charges","neg_dollar:$5.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.00","Fee Schedule","","5.00","10.00",""
"LIDOCAINE HCL (PF) 1 % IJ SOLN","J2003","HCPCS","55150-161-02","NDC","636","RC","","Facility","Outpatient","1","EA","1.44","1.44","","","","1.44","Fee Schedule","","","","","1.44","Fee Schedule","101% of Medicare Fee Schedule","","","","1.44","Fee Schedule","","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.44","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.44","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.44","150","","","Percent of Total Billed Charges","neg_dollar:$2.23;150% of Medicaid interim rate","1.15","80","","","Percent of Total Billed Charges","neg_dollar:$1.15;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE HCL (PF) 1 % IJ SOLN","J2003","HCPCS","55150-162-05","NDC","636","RC","","Facility","Outpatient","1","EA","0.06","0.06","","","","0.06","Fee Schedule","","","","","0.06","Fee Schedule","101% of Medicare Fee Schedule","","","","0.06","Fee Schedule","","0.03","52","","","Percent of Total Billed Charges","neg_dollar:$0.03;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.05","86","","","Percent of Total Billed Charges","neg_dollar:$0.05","0.04","70","","","Percent of Total Billed Charges","neg_dollar:$0.04","0.03","52","","","Percent of Total Billed Charges","neg_dollar:$0.03;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.03;102% of Medicaid interim rate","0.04","75","","","Percent of Total Billed Charges","neg_dollar:$0.04","0.05","86","","","Percent of Total Billed Charges","neg_dollar:$0.05","0.04","70","","","Percent of Total Billed Charges","neg_dollar:$0.04","0.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.03;103.5% of Medicaid interim rate","0.06","150","","","Percent of Total Billed Charges","neg_dollar:$0.09;150% of Medicaid interim rate","0.04","80","","","Percent of Total Billed Charges","neg_dollar:$0.04;Percent of Total Billed Charges","0.05","92","","","Percent of Total Billed Charges","neg_dollar:$0.05","0.03","52","","","Percent of Total Billed Charges","neg_dollar:$0.03;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.03","52","","","Percent of Total Billed Charges","neg_dollar:$0.03;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE HCL (PF) 1 % IJ SOLN","J2003","HCPCS","55150-162-05","NDC","636","RC","","Facility","Outpatient","1","EA","1.74","1.74","","","","1.74","Fee Schedule","","","","","1.74","Fee Schedule","101% of Medicare Fee Schedule","","","","1.74","Fee Schedule","","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.49","86","","","Percent of Total Billed Charges","neg_dollar:$1.49","1.21","70","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.30","75","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.49","86","","","Percent of Total Billed Charges","neg_dollar:$1.49","1.21","70","","","Percent of Total Billed Charges","neg_dollar:$1.21","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.74","150","","","Percent of Total Billed Charges","neg_dollar:$2.69;150% of Medicaid interim rate","1.39","80","","","Percent of Total Billed Charges","neg_dollar:$1.39;Percent of Total Billed Charges","1.60","92","","","Percent of Total Billed Charges","neg_dollar:$1.60","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","52","","","Percent of Total Billed Charges","neg_dollar:$0.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE HCL (PF) 1 % IJ SOLN","J2003","HCPCS","55150-162-05","NDC","636","RC","","Facility","Outpatient","1","EA","1.86","1.86","","","","1.86","Fee Schedule","","","","","1.86","Fee Schedule","101% of Medicare Fee Schedule","","","","1.86","Fee Schedule","","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.60","86","","","Percent of Total Billed Charges","neg_dollar:$1.60","1.30","70","","","Percent of Total Billed Charges","neg_dollar:$1.30","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% of Medicaid interim rate","1.40","75","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.60","86","","","Percent of Total Billed Charges","neg_dollar:$1.60","1.30","70","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.06;103.5% of Medicaid interim rate","1.86","150","","","Percent of Total Billed Charges","neg_dollar:$2.88;150% of Medicaid interim rate","1.49","80","","","Percent of Total Billed Charges","neg_dollar:$1.49;Percent of Total Billed Charges","1.71","92","","","Percent of Total Billed Charges","neg_dollar:$1.71","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE HCL 1 % IJ SOLN","J2003","HCPCS","00143-9577-01","NDC","636","RC","","Facility","Outpatient","1","EA","8.76","8.76","","","","8.76","Fee Schedule","","","","","8.76","Fee Schedule","101% of Medicare Fee Schedule","","","","8.76","Fee Schedule","","4.55","52","","","Percent of Total Billed Charges","neg_dollar:$4.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.76","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.76","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.53","86","","","Percent of Total Billed Charges","neg_dollar:$7.53","6.13","70","","","Percent of Total Billed Charges","neg_dollar:$6.13","4.55","52","","","Percent of Total Billed Charges","neg_dollar:$4.55;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.14;102% of Medicaid interim rate","6.57","75","","","Percent of Total Billed Charges","neg_dollar:$6.57","7.53","86","","","Percent of Total Billed Charges","neg_dollar:$7.53","6.13","70","","","Percent of Total Billed Charges","neg_dollar:$6.13","4.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.99;103.5% of Medicaid interim rate","8.76","150","","","Percent of Total Billed Charges","neg_dollar:$13.55;150% of Medicaid interim rate","7.01","80","","","Percent of Total Billed Charges","neg_dollar:$7.01;Percent of Total Billed Charges","8.06","92","","","Percent of Total Billed Charges","neg_dollar:$8.06","4.55","52","","","Percent of Total Billed Charges","neg_dollar:$4.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.55","52","","","Percent of Total Billed Charges","neg_dollar:$4.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","8.00",""
"LIDOCAINE HCL (PF) 1 % IJ SOLN","J2003","HCPCS","55150-162-05","NDC","250","RC","","Facility","Outpatient","1","EA","1.62","1.62","","","","1.62","Fee Schedule","","","","","1.62","Fee Schedule","","","","","1.62","Fee Schedule","","","52","","1.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.39","86","","","Percent of Total Billed Charges","neg_dollar:$1.39","1.13","70","","","Percent of Total Billed Charges","neg_dollar:$1.13","","52","","1.62","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% of Medicaid interim rate","1.21","75","","","Percent of Total Billed Charges","neg_dollar:$1.21","1.39","86","","","Percent of Total Billed Charges","neg_dollar:$1.39","1.13","70","","","Percent of Total Billed Charges","neg_dollar:$1.13","0.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.92;103.5% of Medicaid interim rate","1.62","150","","","Percent of Total Billed Charges","neg_dollar:$2.51;150% of Medicaid interim rate","1.30","80","","","Percent of Total Billed Charges","neg_dollar:$1.30;Percent of Total Billed Charges","1.49","92","","","Percent of Total Billed Charges","neg_dollar:$1.49","0.84","52","","","Percent of Total Billed Charges","neg_dollar:$0.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.62","Fee Schedule","","1.00","1.00",""
"LIDOCAINE HCL 100 MG/5ML IJ SOSY","J2003","HCPCS","76329-3390-1","NDC","636","RC","","Facility","Outpatient","100","EA","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","101% of Medicare Fee Schedule","","","","1.05","Fee Schedule","","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.79","75","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.63;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.97","92","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE HCL (CARDIAC) 100 MG/5ML IV SOSY","J2003","HCPCS","00409-4903-11","NDC","636","RC","","Facility","Outpatient","100","EA","1","1.00","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% of Medicaid interim rate","0.75","75","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.00","150","","","Percent of Total Billed Charges","neg_dollar:$1.54;150% of Medicaid interim rate","0.80","80","","","Percent of Total Billed Charges","neg_dollar:$0.80;Percent of Total Billed Charges","0.92","92","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE HCL (PF) 2 % IJ SOLN","J2003","HCPCS","55150-165-05","NDC","250","RC","","Facility","Outpatient","1","EA","0.92","0.92","","","","0.92","Fee Schedule","","","","","0.92","Fee Schedule","","","","","0.92","Fee Schedule","","","52","","0.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","86","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.64","70","","","Percent of Total Billed Charges","neg_dollar:$0.64","","52","","0.92","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% of Medicaid interim rate","0.69","75","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.79","86","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.64","70","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;103.5% of Medicaid interim rate","0.92","150","","","Percent of Total Billed Charges","neg_dollar:$1.43;150% of Medicaid interim rate","0.74","80","","","Percent of Total Billed Charges","neg_dollar:$0.74;Percent of Total Billed Charges","0.85","92","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.92","Fee Schedule","","1.00","1.00",""
"LIDOCAINE HCL (PF) 2 % IJ SOLN","J2003","HCPCS","00143-9594-25","NDC","636","RC","","Facility","Outpatient","1","EA","0.02","0.02","","","","0.02","Fee Schedule","","","","","0.02","Fee Schedule","101% of Medicare Fee Schedule","","","","0.02","Fee Schedule","","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.01","86","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.01","70","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.01;102% of Medicaid interim rate","0.01","75","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.01","86","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.01","70","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.01;103.5% of Medicaid interim rate","0.02","150","","","Percent of Total Billed Charges","neg_dollar:$0.03;150% of Medicaid interim rate","0.01","80","","","Percent of Total Billed Charges","neg_dollar:$0.01;Percent of Total Billed Charges","0.02","92","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE HCL (PF) 2 % IJ SOLN","J2003","HCPCS","55150-165-05","NDC","636","RC","","Facility","Outpatient","1","EA","0.02","0.02","","","","0.02","Fee Schedule","","","","","0.02","Fee Schedule","101% of Medicare Fee Schedule","","","","0.02","Fee Schedule","","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.02","86","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.01","70","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.01;102% of Medicaid interim rate","0.01","75","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.02","86","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.01","70","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.01;103.5% of Medicaid interim rate","0.02","150","","","Percent of Total Billed Charges","neg_dollar:$0.04;150% of Medicaid interim rate","0.02","80","","","Percent of Total Billed Charges","neg_dollar:$0.02;Percent of Total Billed Charges","0.02","92","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE HCL (PF) 2 % IJ SOLN","J2003","HCPCS","55150-165-05","NDC","636","RC","","Facility","Outpatient","1","EA","0.92","0.92","","","","0.92","Fee Schedule","","","","","0.92","Fee Schedule","101% of Medicare Fee Schedule","","","","0.92","Fee Schedule","","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","86","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.64","70","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% of Medicaid interim rate","0.69","75","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.79","86","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.64","70","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;103.5% of Medicaid interim rate","0.92","150","","","Percent of Total Billed Charges","neg_dollar:$1.43;150% of Medicaid interim rate","0.74","80","","","Percent of Total Billed Charges","neg_dollar:$0.74;Percent of Total Billed Charges","0.85","92","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE HCL (PF) 2 % IJ SOLN","J2003","HCPCS","00143-9594-25","NDC","636","RC","","Facility","Outpatient","1","EA","0.90","0.90","","","","0.90","Fee Schedule","","","","","0.90","Fee Schedule","101% of Medicare Fee Schedule","","","","0.90","Fee Schedule","","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% of Medicaid interim rate","0.68","75","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.90","150","","","Percent of Total Billed Charges","neg_dollar:$1.40;150% of Medicaid interim rate","0.72","80","","","Percent of Total Billed Charges","neg_dollar:$0.72;Percent of Total Billed Charges","0.83","92","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE HCL (PF) 2 % IJ SOLN","J2003","HCPCS","00143-9594-25","NDC","636","RC","","Facility","Outpatient","1","EA","0.91","0.91","","","","0.91","Fee Schedule","","","","","0.91","Fee Schedule","101% of Medicare Fee Schedule","","","","0.91","Fee Schedule","","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","86","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.64","70","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% of Medicaid interim rate","0.68","75","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.79","86","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.64","70","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;103.5% of Medicaid interim rate","0.91","150","","","Percent of Total Billed Charges","neg_dollar:$1.42;150% of Medicaid interim rate","0.73","80","","","Percent of Total Billed Charges","neg_dollar:$0.73;Percent of Total Billed Charges","0.84","92","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","J2004","HCPCS","63323-482-27","NDC","636","RC","","Facility","Outpatient","1","EA","0.79","0.79","","","","0.79","Fee Schedule","","","","","0.79","Fee Schedule","101% of Medicare Fee Schedule","","","","0.79","Fee Schedule","","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.59","75","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.79","150","","","Percent of Total Billed Charges","neg_dollar:$1.23;150% of Medicaid interim rate","0.63","80","","","Percent of Total Billed Charges","neg_dollar:$0.63;Percent of Total Billed Charges","0.73","92","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","J2004","HCPCS","63323-482-27","NDC","250","RC","","Facility","Outpatient","1","EA","1.21","1.21","","","","1.21","Fee Schedule","","","","","1.21","Fee Schedule","","","","","1.21","Fee Schedule","","","52","","1.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","86","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","","52","","1.21","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;102% of Medicaid interim rate","0.91","75","","","Percent of Total Billed Charges","neg_dollar:$0.91","1.04","86","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","70","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;103.5% of Medicaid interim rate","1.21","150","","","Percent of Total Billed Charges","neg_dollar:$1.88;150% of Medicaid interim rate","0.97","80","","","Percent of Total Billed Charges","neg_dollar:$0.97;Percent of Total Billed Charges","1.12","92","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.63","52","","","Percent of Total Billed Charges","neg_dollar:$0.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.21","Fee Schedule","","1.00","1.00",""
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","J2004","HCPCS","63323-482-27","NDC","636","RC","","Facility","Outpatient","1","EA","0.02","0.02","","","","0.02","Fee Schedule","","","","","0.02","Fee Schedule","101% of Medicare Fee Schedule","","","","0.02","Fee Schedule","","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.02","86","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.01","70","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.01;102% of Medicaid interim rate","0.01","75","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.02","86","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.01","70","","","Percent of Total Billed Charges","neg_dollar:$0.01","0.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.01;103.5% of Medicaid interim rate","0.02","150","","","Percent of Total Billed Charges","neg_dollar:$0.04;150% of Medicaid interim rate","0.02","80","","","Percent of Total Billed Charges","neg_dollar:$0.02;Percent of Total Billed Charges","0.02","92","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN","J2004","HCPCS","63323-483-27","NDC","636","RC","","Facility","Outpatient","1","EA","4.39","4.39","","","","4.39","Fee Schedule","","","","","4.39","Fee Schedule","101% of Medicare Fee Schedule","","","","4.39","Fee Schedule","","2.28","52","","","Percent of Total Billed Charges","neg_dollar:$2.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.39","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.39","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.77","86","","","Percent of Total Billed Charges","neg_dollar:$3.77","3.07","70","","","Percent of Total Billed Charges","neg_dollar:$3.07","2.28","52","","","Percent of Total Billed Charges","neg_dollar:$2.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.58;102% of Medicaid interim rate","3.29","75","","","Percent of Total Billed Charges","neg_dollar:$3.29","3.77","86","","","Percent of Total Billed Charges","neg_dollar:$3.77","3.07","70","","","Percent of Total Billed Charges","neg_dollar:$3.07","2.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.50;103.5% of Medicaid interim rate","4.39","150","","","Percent of Total Billed Charges","neg_dollar:$6.79;150% of Medicaid interim rate","3.51","80","","","Percent of Total Billed Charges","neg_dollar:$3.51;Percent of Total Billed Charges","4.04","92","","","Percent of Total Billed Charges","neg_dollar:$4.04","2.28","52","","","Percent of Total Billed Charges","neg_dollar:$2.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.28","52","","","Percent of Total Billed Charges","neg_dollar:$2.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN","J2004","HCPCS","63323-483-03","NDC","636","RC","","Facility","Outpatient","1","EA","0.45","0.45","","","","0.45","Fee Schedule","","","","","0.45","Fee Schedule","101% of Medicare Fee Schedule","","","","0.45","Fee Schedule","","0.23","52","","","Percent of Total Billed Charges","neg_dollar:$0.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","86","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.32","70","","","Percent of Total Billed Charges","neg_dollar:$0.32","0.23","52","","","Percent of Total Billed Charges","neg_dollar:$0.23;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% of Medicaid interim rate","0.34","75","","","Percent of Total Billed Charges","neg_dollar:$0.34","0.39","86","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.32","70","","","Percent of Total Billed Charges","neg_dollar:$0.32","0.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.26;103.5% of Medicaid interim rate","0.45","150","","","Percent of Total Billed Charges","neg_dollar:$0.70;150% of Medicaid interim rate","0.36","80","","","Percent of Total Billed Charges","neg_dollar:$0.36;Percent of Total Billed Charges","0.42","92","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.23","52","","","Percent of Total Billed Charges","neg_dollar:$0.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.23","52","","","Percent of Total Billed Charges","neg_dollar:$0.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LORAZEPAM 2 MG/ML IJ SOLN","J2060","HCPCS","00641-6207-01","NDC","250","RC","","Facility","Outpatient","1","ML","88.54","88.54","","","","1.00","Fee Schedule","","","","","45.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","88.54","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.04","52","","","Percent of Total Billed Charges","neg_dollar:$46.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.04","52","","","Percent of Total Billed Charges","neg_dollar:$46.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.14","86","","","Percent of Total Billed Charges","neg_dollar:$76.14","61.98","70","","","Percent of Total Billed Charges","neg_dollar:$61.98","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.01;102% of Medicaid interim rate","66.40","75","","","Percent of Total Billed Charges","neg_dollar:$66.40","76.14","86","","","Percent of Total Billed Charges","neg_dollar:$76.14","61.98","70","","","Percent of Total Billed Charges","neg_dollar:$61.98","50.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.47;103.5% of Medicaid interim rate","88.54","150","","","Percent of Total Billed Charges","neg_dollar:$136.89;150% of Medicaid interim rate","70.83","80","","","Percent of Total Billed Charges","neg_dollar:$70.83;Percent of Total Billed Charges","81.46","92","","","Percent of Total Billed Charges","neg_dollar:$81.46","46.04","52","","","Percent of Total Billed Charges","neg_dollar:$46.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"LORAZEPAM 2 MG/ML IJ SOLN","J2060","HCPCS","00641-6207-25","NDC","636","RC","","Facility","Outpatient","1","ML","88.63","88.63","","","","1.00","Fee Schedule","","","","","45.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.08","52","","","Percent of Total Billed Charges","neg_dollar:$46.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.22","86","","","Percent of Total Billed Charges","neg_dollar:$76.22","62.04","70","","","Percent of Total Billed Charges","neg_dollar:$62.04","46.08","52","","","Percent of Total Billed Charges","neg_dollar:$46.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.07;102% of Medicaid interim rate","66.47","75","","","Percent of Total Billed Charges","neg_dollar:$66.47","76.22","86","","","Percent of Total Billed Charges","neg_dollar:$76.22","62.04","70","","","Percent of Total Billed Charges","neg_dollar:$62.04","50.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.52;103.5% of Medicaid interim rate","88.63","150","","","Percent of Total Billed Charges","neg_dollar:$137.03;150% of Medicaid interim rate","70.90","80","","","Percent of Total Billed Charges","neg_dollar:$70.90;Percent of Total Billed Charges","81.54","92","","","Percent of Total Billed Charges","neg_dollar:$81.54","46.08","52","","","Percent of Total Billed Charges","neg_dollar:$46.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.08","52","","","Percent of Total Billed Charges","neg_dollar:$46.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"LORAZEPAM 2 MG/ML IJ SOLN","J2060","HCPCS","00641-6207-25","NDC","250","RC","","Facility","Outpatient","1","ML","88.70","88.70","","","","1.00","Fee Schedule","","","","","45.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","88.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.12","52","","","Percent of Total Billed Charges","neg_dollar:$46.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.12","52","","","Percent of Total Billed Charges","neg_dollar:$46.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.28","86","","","Percent of Total Billed Charges","neg_dollar:$76.28","62.08","70","","","Percent of Total Billed Charges","neg_dollar:$62.08","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.11;102% of Medicaid interim rate","66.52","75","","","Percent of Total Billed Charges","neg_dollar:$66.52","76.28","86","","","Percent of Total Billed Charges","neg_dollar:$76.28","62.08","70","","","Percent of Total Billed Charges","neg_dollar:$62.08","50.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.55;103.5% of Medicaid interim rate","88.70","150","","","Percent of Total Billed Charges","neg_dollar:$137.13;150% of Medicaid interim rate","70.96","80","","","Percent of Total Billed Charges","neg_dollar:$70.96;Percent of Total Billed Charges","81.60","92","","","Percent of Total Billed Charges","neg_dollar:$81.60","46.12","52","","","Percent of Total Billed Charges","neg_dollar:$46.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"LORAZEPAM 2 MG/ML IJ SOLN","J2060","HCPCS","00641-6044-01","NDC","636","RC","","Facility","Outpatient","1","ML","88.63","88.63","","","","1.00","Fee Schedule","","","","","45.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.09","52","","","Percent of Total Billed Charges","neg_dollar:$46.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.22","86","","","Percent of Total Billed Charges","neg_dollar:$76.22","62.04","70","","","Percent of Total Billed Charges","neg_dollar:$62.04","46.09","52","","","Percent of Total Billed Charges","neg_dollar:$46.09;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.07;102% of Medicaid interim rate","66.47","75","","","Percent of Total Billed Charges","neg_dollar:$66.47","76.22","86","","","Percent of Total Billed Charges","neg_dollar:$76.22","62.04","70","","","Percent of Total Billed Charges","neg_dollar:$62.04","50.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.52;103.5% of Medicaid interim rate","88.63","150","","","Percent of Total Billed Charges","neg_dollar:$137.03;150% of Medicaid interim rate","70.91","80","","","Percent of Total Billed Charges","neg_dollar:$70.91;Percent of Total Billed Charges","81.54","92","","","Percent of Total Billed Charges","neg_dollar:$81.54","46.09","52","","","Percent of Total Billed Charges","neg_dollar:$46.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.09","52","","","Percent of Total Billed Charges","neg_dollar:$46.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"LORAZEPAM 2 MG/ML IJ SOLN","J2060","HCPCS","00641-6044-01","NDC","250","RC","","Facility","Outpatient","1","ML","88.83","88.83","","","","1.00","Fee Schedule","","","","","45.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","88.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.19","52","","","Percent of Total Billed Charges","neg_dollar:$46.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.19","52","","","Percent of Total Billed Charges","neg_dollar:$46.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.39","86","","","Percent of Total Billed Charges","neg_dollar:$76.39","62.18","70","","","Percent of Total Billed Charges","neg_dollar:$62.18","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.19;102% of Medicaid interim rate","66.62","75","","","Percent of Total Billed Charges","neg_dollar:$66.62","76.39","86","","","Percent of Total Billed Charges","neg_dollar:$76.39","62.18","70","","","Percent of Total Billed Charges","neg_dollar:$62.18","50.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.63;103.5% of Medicaid interim rate","88.83","150","","","Percent of Total Billed Charges","neg_dollar:$137.34;150% of Medicaid interim rate","71.06","80","","","Percent of Total Billed Charges","neg_dollar:$71.06;Percent of Total Billed Charges","81.72","92","","","Percent of Total Billed Charges","neg_dollar:$81.72","46.19","52","","","Percent of Total Billed Charges","neg_dollar:$46.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"LORAZEPAM 2 MG/ML IJ SOLN","J2060","HCPCS","00641-6044-25","NDC","636","RC","","Facility","Outpatient","1","ML","46.60","46.60","","","","1.00","Fee Schedule","","","","","45.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","24.23","52","","","Percent of Total Billed Charges","neg_dollar:$24.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","46.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","46.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","40.07","86","","","Percent of Total Billed Charges","neg_dollar:$40.07","32.62","70","","","Percent of Total Billed Charges","neg_dollar:$32.62","24.23","52","","","Percent of Total Billed Charges","neg_dollar:$24.23;105% Medicare Outpatient Cost to Charge Ratio of 52%","27.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.37;102% of Medicaid interim rate","34.95","75","","","Percent of Total Billed Charges","neg_dollar:$34.95","40.07","86","","","Percent of Total Billed Charges","neg_dollar:$40.07","32.62","70","","","Percent of Total Billed Charges","neg_dollar:$32.62","26.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.56;103.5% of Medicaid interim rate","46.60","150","","","Percent of Total Billed Charges","neg_dollar:$72.04;150% of Medicaid interim rate","37.28","80","","","Percent of Total Billed Charges","neg_dollar:$37.28;Percent of Total Billed Charges","42.87","92","","","Percent of Total Billed Charges","neg_dollar:$42.87","24.23","52","","","Percent of Total Billed Charges","neg_dollar:$24.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","24.23","52","","","Percent of Total Billed Charges","neg_dollar:$24.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","46.00",""
"LORAZEPAM 2 MG/ML IJ SOLN","J2060","HCPCS","00641-6207-01","NDC","636","RC","","Facility","Outpatient","1","ML","88.65","88.65","","","","1.00","Fee Schedule","","","","","45.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.09","52","","","Percent of Total Billed Charges","neg_dollar:$46.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.23","86","","","Percent of Total Billed Charges","neg_dollar:$76.23","62.05","70","","","Percent of Total Billed Charges","neg_dollar:$62.05","46.09","52","","","Percent of Total Billed Charges","neg_dollar:$46.09;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.08;102% of Medicaid interim rate","66.48","75","","","Percent of Total Billed Charges","neg_dollar:$66.48","76.23","86","","","Percent of Total Billed Charges","neg_dollar:$76.23","62.05","70","","","Percent of Total Billed Charges","neg_dollar:$62.05","50.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.53;103.5% of Medicaid interim rate","88.65","150","","","Percent of Total Billed Charges","neg_dollar:$137.05;150% of Medicaid interim rate","70.92","80","","","Percent of Total Billed Charges","neg_dollar:$70.92;Percent of Total Billed Charges","81.55","92","","","Percent of Total Billed Charges","neg_dollar:$81.55","46.09","52","","","Percent of Total Billed Charges","neg_dollar:$46.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.09","52","","","Percent of Total Billed Charges","neg_dollar:$46.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"MEROPENEM 1 G IV SOLR","J2183","HCPCS","44567-401-01","NDC","250","RC","","Facility","Outpatient","1","UN","10.25","10.25","","","","10.25","Fee Schedule","","","","","10.25","Fee Schedule","","","","","10.25","Fee Schedule","","","52","","10.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.33","52","","","Percent of Total Billed Charges","neg_dollar:$5.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.33","52","","","Percent of Total Billed Charges","neg_dollar:$5.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.81","86","","","Percent of Total Billed Charges","neg_dollar:$8.81","7.17","70","","","Percent of Total Billed Charges","neg_dollar:$7.17","","52","","10.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.02;102% of Medicaid interim rate","7.68","75","","","Percent of Total Billed Charges","neg_dollar:$7.68","8.81","86","","","Percent of Total Billed Charges","neg_dollar:$8.81","7.17","70","","","Percent of Total Billed Charges","neg_dollar:$7.17","5.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.84;103.5% of Medicaid interim rate","10.25","150","","","Percent of Total Billed Charges","neg_dollar:$15.84;150% of Medicaid interim rate","8.20","80","","","Percent of Total Billed Charges","neg_dollar:$8.20;Percent of Total Billed Charges","9.43","92","","","Percent of Total Billed Charges","neg_dollar:$9.43","5.33","52","","","Percent of Total Billed Charges","neg_dollar:$5.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.25","Fee Schedule","","5.00","10.00",""
"MEROPENEM 1 G IV SOLR","J2185","HCPCS","63323-508-30","NDC","250","RC","","Facility","Outpatient","1","UN","5.58","5.58","","","","5.58","Fee Schedule","","","","","5.58","Fee Schedule","","","","","5.58","Fee Schedule","","","52","","5.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.90","52","","","Percent of Total Billed Charges","neg_dollar:$2.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.90","52","","","Percent of Total Billed Charges","neg_dollar:$2.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.80","86","","","Percent of Total Billed Charges","neg_dollar:$4.80","3.91","70","","","Percent of Total Billed Charges","neg_dollar:$3.91","","52","","5.58","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.28;102% of Medicaid interim rate","4.19","75","","","Percent of Total Billed Charges","neg_dollar:$4.19","4.80","86","","","Percent of Total Billed Charges","neg_dollar:$4.80","3.91","70","","","Percent of Total Billed Charges","neg_dollar:$3.91","3.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.18;103.5% of Medicaid interim rate","5.58","150","","","Percent of Total Billed Charges","neg_dollar:$8.63;150% of Medicaid interim rate","4.46","80","","","Percent of Total Billed Charges","neg_dollar:$4.46;Percent of Total Billed Charges","5.14","92","","","Percent of Total Billed Charges","neg_dollar:$5.14","2.90","52","","","Percent of Total Billed Charges","neg_dollar:$2.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.58","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"MEROPENEM 1 G IV SOLR","J2185","HCPCS","63323-508-30","NDC","636","RC","","Facility","Outpatient","1","UN","6.18","6.18","","","","6.18","Fee Schedule","","","","","6.18","Fee Schedule","101% of Medicare Fee Schedule","","","","6.18","Fee Schedule","","3.21","52","","","Percent of Total Billed Charges","neg_dollar:$3.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","6.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","6.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.31","86","","","Percent of Total Billed Charges","neg_dollar:$5.31","4.32","70","","","Percent of Total Billed Charges","neg_dollar:$4.32","3.21","52","","","Percent of Total Billed Charges","neg_dollar:$3.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","3.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.63;102% of Medicaid interim rate","4.63","75","","","Percent of Total Billed Charges","neg_dollar:$4.63","5.31","86","","","Percent of Total Billed Charges","neg_dollar:$5.31","4.32","70","","","Percent of Total Billed Charges","neg_dollar:$4.32","3.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.52;103.5% of Medicaid interim rate","6.18","150","","","Percent of Total Billed Charges","neg_dollar:$9.55;150% of Medicaid interim rate","4.94","80","","","Percent of Total Billed Charges","neg_dollar:$4.94;Percent of Total Billed Charges","5.68","92","","","Percent of Total Billed Charges","neg_dollar:$5.68","3.21","52","","","Percent of Total Billed Charges","neg_dollar:$3.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.21","52","","","Percent of Total Billed Charges","neg_dollar:$3.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","6.00",""
"MEROPENEM 1 G IV SOLR","J2185","HCPCS","63323-508-30","NDC","250","RC","","Facility","Outpatient","1","UN","5.55","5.55","","","","5.55","Fee Schedule","","","","","5.55","Fee Schedule","","","","","5.55","Fee Schedule","","","52","","5.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.77","86","","","Percent of Total Billed Charges","neg_dollar:$4.77","3.88","70","","","Percent of Total Billed Charges","neg_dollar:$3.88","","52","","5.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.26;102% of Medicaid interim rate","4.16","75","","","Percent of Total Billed Charges","neg_dollar:$4.16","4.77","86","","","Percent of Total Billed Charges","neg_dollar:$4.77","3.88","70","","","Percent of Total Billed Charges","neg_dollar:$3.88","3.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.16;103.5% of Medicaid interim rate","5.55","150","","","Percent of Total Billed Charges","neg_dollar:$8.58;150% of Medicaid interim rate","4.44","80","","","Percent of Total Billed Charges","neg_dollar:$4.44;Percent of Total Billed Charges","5.11","92","","","Percent of Total Billed Charges","neg_dollar:$5.11","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.55","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"MICAFUNGIN SODIUM 100 MG IV SOLR","J2248","HCPCS","63323-729-10","NDC","636","RC","","Facility","Outpatient","100","UN","1.83","1.83","","","","1.83","Fee Schedule","","","","","1.83","Fee Schedule","101% of Medicare Fee Schedule","","","","1.83","Fee Schedule","","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.57","86","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.07;102% of Medicaid interim rate","1.37","75","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.57","86","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","1.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.04;103.5% of Medicaid interim rate","1.83","150","","","Percent of Total Billed Charges","neg_dollar:$2.83;150% of Medicaid interim rate","1.46","80","","","Percent of Total Billed Charges","neg_dollar:$1.46;Percent of Total Billed Charges","1.68","92","","","Percent of Total Billed Charges","neg_dollar:$1.68","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MICAFUNGIN SODIUM 100 MG IV SOLR","J2248","HCPCS","63323-729-01","NDC","636","RC","","Facility","Outpatient","100","UN","1.83","1.83","","","","1.83","Fee Schedule","","","","","1.83","Fee Schedule","101% of Medicare Fee Schedule","","","","1.83","Fee Schedule","","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.57","86","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.07;102% of Medicaid interim rate","1.37","75","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.57","86","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.28","70","","","Percent of Total Billed Charges","neg_dollar:$1.28","1.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.04;103.5% of Medicaid interim rate","1.83","150","","","Percent of Total Billed Charges","neg_dollar:$2.83;150% of Medicaid interim rate","1.46","80","","","Percent of Total Billed Charges","neg_dollar:$1.46;Percent of Total Billed Charges","1.68","92","","","Percent of Total Billed Charges","neg_dollar:$1.68","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.95","52","","","Percent of Total Billed Charges","neg_dollar:$0.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"REMIMAZOLAM BESYLATE 20 MG IV SOLR","J2249","HCPCS","71390-011-00","NDC","636","RC","","Facility","Outpatient","1","UN","8.75","8.75","","","","8.75","Fee Schedule","","","","","8.75","Fee Schedule","101% of Medicare Fee Schedule","","","","8.75","Fee Schedule","","4.55","52","","","Percent of Total Billed Charges","neg_dollar:$4.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.53","86","","","Percent of Total Billed Charges","neg_dollar:$7.53","6.13","70","","","Percent of Total Billed Charges","neg_dollar:$6.13","4.55","52","","","Percent of Total Billed Charges","neg_dollar:$4.55;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.14;102% of Medicaid interim rate","6.56","75","","","Percent of Total Billed Charges","neg_dollar:$6.56","7.53","86","","","Percent of Total Billed Charges","neg_dollar:$7.53","6.13","70","","","Percent of Total Billed Charges","neg_dollar:$6.13","4.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.99;103.5% of Medicaid interim rate","8.75","150","","","Percent of Total Billed Charges","neg_dollar:$13.53;150% of Medicaid interim rate","7.00","80","","","Percent of Total Billed Charges","neg_dollar:$7;Percent of Total Billed Charges","8.05","92","","","Percent of Total Billed Charges","neg_dollar:$8.05","4.55","52","","","Percent of Total Billed Charges","neg_dollar:$4.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.55","52","","","Percent of Total Billed Charges","neg_dollar:$4.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","8.00",""
"REMIMAZOLAM BESYLATE 20 MG IV SOLR","J2249","HCPCS","71390-011-00","NDC","636","RC","","Facility","Outpatient","1","UN","2.75","2.75","","","","2.75","Fee Schedule","","","","","2.75","Fee Schedule","101% of Medicare Fee Schedule","","","","2.75","Fee Schedule","","1.43","52","","","Percent of Total Billed Charges","neg_dollar:$1.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.36","86","","","Percent of Total Billed Charges","neg_dollar:$2.36","1.92","70","","","Percent of Total Billed Charges","neg_dollar:$1.92","1.43","52","","","Percent of Total Billed Charges","neg_dollar:$1.43;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% of Medicaid interim rate","2.06","75","","","Percent of Total Billed Charges","neg_dollar:$2.06","2.36","86","","","Percent of Total Billed Charges","neg_dollar:$2.36","1.92","70","","","Percent of Total Billed Charges","neg_dollar:$1.92","1.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.56;103.5% of Medicaid interim rate","2.75","150","","","Percent of Total Billed Charges","neg_dollar:$4.25;150% of Medicaid interim rate","2.20","80","","","Percent of Total Billed Charges","neg_dollar:$2.20;Percent of Total Billed Charges","2.53","92","","","Percent of Total Billed Charges","neg_dollar:$2.53","1.43","52","","","Percent of Total Billed Charges","neg_dollar:$1.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.43","52","","","Percent of Total Billed Charges","neg_dollar:$1.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"MIDAZOLAM HCL 10 MG/10ML IJ SOLN","J2250","HCPCS","00409-2305-16","NDC","636","RC","","Facility","Outpatient","10","ML","88.60","88.60","","","","88.60","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","88.60","Fee Schedule","","46.07","52","","","Percent of Total Billed Charges","neg_dollar:$46.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.19","86","","","Percent of Total Billed Charges","neg_dollar:$76.19","62.01","70","","","Percent of Total Billed Charges","neg_dollar:$62.01","46.07","52","","","Percent of Total Billed Charges","neg_dollar:$46.07;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.05;102% of Medicaid interim rate","66.44","75","","","Percent of Total Billed Charges","neg_dollar:$66.44","76.19","86","","","Percent of Total Billed Charges","neg_dollar:$76.19","62.01","70","","","Percent of Total Billed Charges","neg_dollar:$62.01","50.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.50;103.5% of Medicaid interim rate","88.60","150","","","Percent of Total Billed Charges","neg_dollar:$136.98;150% of Medicaid interim rate","70.88","80","","","Percent of Total Billed Charges","neg_dollar:$70.88;Percent of Total Billed Charges","81.51","92","","","Percent of Total Billed Charges","neg_dollar:$81.51","46.07","52","","","Percent of Total Billed Charges","neg_dollar:$46.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.07","52","","","Percent of Total Billed Charges","neg_dollar:$46.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.00","88.00",""
"MIDAZOLAM HCL 10 MG/10ML IJ SOLN","J2250","HCPCS","00641-6056-10","NDC","636","RC","","Facility","Outpatient","10","ML","44.20","44.20","","","","44.20","Fee Schedule","","","","","44.20","Fee Schedule","101% of Medicare Fee Schedule","","","","44.20","Fee Schedule","","22.98","52","","","Percent of Total Billed Charges","neg_dollar:$22.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","44.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","44.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","38.01","86","","","Percent of Total Billed Charges","neg_dollar:$38.01","30.94","70","","","Percent of Total Billed Charges","neg_dollar:$30.94","22.98","52","","","Percent of Total Billed Charges","neg_dollar:$22.98;105% Medicare Outpatient Cost to Charge Ratio of 52%","25.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.96;102% of Medicaid interim rate","33.15","75","","","Percent of Total Billed Charges","neg_dollar:$33.15","38.01","86","","","Percent of Total Billed Charges","neg_dollar:$38.01","30.94","70","","","Percent of Total Billed Charges","neg_dollar:$30.94","25.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.19;103.5% of Medicaid interim rate","44.20","150","","","Percent of Total Billed Charges","neg_dollar:$68.33;150% of Medicaid interim rate","35.36","80","","","Percent of Total Billed Charges","neg_dollar:$35.36;Percent of Total Billed Charges","40.66","92","","","Percent of Total Billed Charges","neg_dollar:$40.66","22.98","52","","","Percent of Total Billed Charges","neg_dollar:$22.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","22.98","52","","","Percent of Total Billed Charges","neg_dollar:$22.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","22.00","44.00",""
"MIDAZOLAM HCL (PF) 2 MG/2ML IJ SOLN","J2250","HCPCS","00409-2305-16","NDC","636","RC","","Facility","Outpatient","2","ML","52.98","52.98","","","","52.98","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","52.98","Fee Schedule","","27.55","52","","","Percent of Total Billed Charges","neg_dollar:$27.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","52.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","52.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.56","86","","","Percent of Total Billed Charges","neg_dollar:$45.56","37.09","70","","","Percent of Total Billed Charges","neg_dollar:$37.09","27.55","52","","","Percent of Total Billed Charges","neg_dollar:$27.55;105% Medicare Outpatient Cost to Charge Ratio of 52%","31.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.13;102% of Medicaid interim rate","39.74","75","","","Percent of Total Billed Charges","neg_dollar:$39.74","45.56","86","","","Percent of Total Billed Charges","neg_dollar:$45.56","37.09","70","","","Percent of Total Billed Charges","neg_dollar:$37.09","30.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.20;103.5% of Medicaid interim rate","52.98","150","","","Percent of Total Billed Charges","neg_dollar:$81.92;150% of Medicaid interim rate","42.39","80","","","Percent of Total Billed Charges","neg_dollar:$42.39;Percent of Total Billed Charges","48.74","92","","","Percent of Total Billed Charges","neg_dollar:$48.74","27.55","52","","","Percent of Total Billed Charges","neg_dollar:$27.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.55","52","","","Percent of Total Billed Charges","neg_dollar:$27.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.00","52.00",""
"MIDAZOLAM HCL (PF) 2 MG/2ML IJ SOLN","J2250","HCPCS","00409-2305-17","NDC","636","RC","","Facility","Outpatient","2","ML","42.07","42.07","","","","42.07","Fee Schedule","","","","","42.07","Fee Schedule","101% of Medicare Fee Schedule","","","","42.07","Fee Schedule","","21.87","52","","","Percent of Total Billed Charges","neg_dollar:$21.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","42.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","42.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","36.18","86","","","Percent of Total Billed Charges","neg_dollar:$36.18","29.45","70","","","Percent of Total Billed Charges","neg_dollar:$29.45","21.87","52","","","Percent of Total Billed Charges","neg_dollar:$21.87;105% Medicare Outpatient Cost to Charge Ratio of 52%","24.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.71;102% of Medicaid interim rate","31.55","75","","","Percent of Total Billed Charges","neg_dollar:$31.55","36.18","86","","","Percent of Total Billed Charges","neg_dollar:$36.18","29.45","70","","","Percent of Total Billed Charges","neg_dollar:$29.45","23.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$23.98;103.5% of Medicaid interim rate","42.07","150","","","Percent of Total Billed Charges","neg_dollar:$65.04;150% of Medicaid interim rate","33.65","80","","","Percent of Total Billed Charges","neg_dollar:$33.65;Percent of Total Billed Charges","38.70","92","","","Percent of Total Billed Charges","neg_dollar:$38.70","21.87","52","","","Percent of Total Billed Charges","neg_dollar:$21.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","21.87","52","","","Percent of Total Billed Charges","neg_dollar:$21.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","21.00","42.00",""
"MIDAZOLAM HCL (PF) 2 MG/2ML IJ SOLN","J2250","HCPCS","00409-2305-17","NDC","636","RC","","Facility","Outpatient","2","ML","0.55","0.55","","","","0.55","Fee Schedule","","","","","0.55","Fee Schedule","101% of Medicare Fee Schedule","","","","0.55","Fee Schedule","","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% of Medicaid interim rate","0.41","75","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.31;103.5% of Medicaid interim rate","0.55","150","","","Percent of Total Billed Charges","neg_dollar:$0.85;150% of Medicaid interim rate","0.44","80","","","Percent of Total Billed Charges","neg_dollar:$0.44;Percent of Total Billed Charges","0.50","92","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MIDAZOLAM HCL (PF) 2 MG/2ML IJ SOLN","J2250","HCPCS","00409-2305-17","NDC","250","RC","","Facility","Outpatient","2","ML","44.82","44.82","","","","44.82","Fee Schedule","","","","","44.82","Fee Schedule","","","","","44.82","Fee Schedule","","","52","","44.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","23.30","52","","","Percent of Total Billed Charges","neg_dollar:$23.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.30","52","","","Percent of Total Billed Charges","neg_dollar:$23.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","38.54","86","","","Percent of Total Billed Charges","neg_dollar:$38.54","31.37","70","","","Percent of Total Billed Charges","neg_dollar:$31.37","","52","","44.82","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","26.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.33;102% of Medicaid interim rate","33.61","75","","","Percent of Total Billed Charges","neg_dollar:$33.61","38.54","86","","","Percent of Total Billed Charges","neg_dollar:$38.54","31.37","70","","","Percent of Total Billed Charges","neg_dollar:$31.37","25.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.55;103.5% of Medicaid interim rate","44.82","150","","","Percent of Total Billed Charges","neg_dollar:$69.30;150% of Medicaid interim rate","35.86","80","","","Percent of Total Billed Charges","neg_dollar:$35.86;Percent of Total Billed Charges","41.23","92","","","Percent of Total Billed Charges","neg_dollar:$41.23","23.30","52","","","Percent of Total Billed Charges","neg_dollar:$23.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","44.82","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","23.00","44.00",""
"MIDAZOLAM HCL 2 MG/2ML IJ SOLN","J2250","HCPCS","00409-2305-16","NDC","636","RC","","Facility","Outpatient","2","ML","46.57","46.57","","","","46.57","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","46.57","Fee Schedule","","24.21","52","","","Percent of Total Billed Charges","neg_dollar:$24.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","46.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","46.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","40.05","86","","","Percent of Total Billed Charges","neg_dollar:$40.05","32.60","70","","","Percent of Total Billed Charges","neg_dollar:$32.60","24.21","52","","","Percent of Total Billed Charges","neg_dollar:$24.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","27.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.36;102% of Medicaid interim rate","34.93","75","","","Percent of Total Billed Charges","neg_dollar:$34.93","40.05","86","","","Percent of Total Billed Charges","neg_dollar:$40.05","32.60","70","","","Percent of Total Billed Charges","neg_dollar:$32.60","26.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.54;103.5% of Medicaid interim rate","46.57","150","","","Percent of Total Billed Charges","neg_dollar:$72;150% of Medicaid interim rate","37.26","80","","","Percent of Total Billed Charges","neg_dollar:$37.26;Percent of Total Billed Charges","42.84","92","","","Percent of Total Billed Charges","neg_dollar:$42.84","24.21","52","","","Percent of Total Billed Charges","neg_dollar:$24.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","24.21","52","","","Percent of Total Billed Charges","neg_dollar:$24.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","24.00","46.00",""
"MIDAZOLAM HCL (PF) 5 MG/ML IJ SOLN","J2250","HCPCS","00409-2308-21","NDC","636","RC","","Facility","Outpatient","1","ML","44.22","44.22","","","","44.22","Fee Schedule","","","","","44.22","Fee Schedule","101% of Medicare Fee Schedule","","","","44.22","Fee Schedule","","22.99","52","","","Percent of Total Billed Charges","neg_dollar:$22.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","44.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","44.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","38.03","86","","","Percent of Total Billed Charges","neg_dollar:$38.03","30.95","70","","","Percent of Total Billed Charges","neg_dollar:$30.95","22.99","52","","","Percent of Total Billed Charges","neg_dollar:$22.99;105% Medicare Outpatient Cost to Charge Ratio of 52%","25.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.98;102% of Medicaid interim rate","33.16","75","","","Percent of Total Billed Charges","neg_dollar:$33.16","38.03","86","","","Percent of Total Billed Charges","neg_dollar:$38.03","30.95","70","","","Percent of Total Billed Charges","neg_dollar:$30.95","25.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.20;103.5% of Medicaid interim rate","44.22","150","","","Percent of Total Billed Charges","neg_dollar:$68.37;150% of Medicaid interim rate","35.38","80","","","Percent of Total Billed Charges","neg_dollar:$35.38;Percent of Total Billed Charges","40.68","92","","","Percent of Total Billed Charges","neg_dollar:$40.68","22.99","52","","","Percent of Total Billed Charges","neg_dollar:$22.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","22.99","52","","","Percent of Total Billed Charges","neg_dollar:$22.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","22.00","44.00",""
"MIDAZOLAM HCL (PF) 5 MG/ML IJ SOLN","J2250","HCPCS","00409-2308-01","NDC","636","RC","","Facility","Outpatient","1","ML","15.05","15.05","","","","15.05","Fee Schedule","","","","","15.05","Fee Schedule","101% of Medicare Fee Schedule","","","","15.05","Fee Schedule","","7.82","52","","","Percent of Total Billed Charges","neg_dollar:$7.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","15.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","15.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.94","86","","","Percent of Total Billed Charges","neg_dollar:$12.94","10.53","70","","","Percent of Total Billed Charges","neg_dollar:$10.53","7.82","52","","","Percent of Total Billed Charges","neg_dollar:$7.82;105% Medicare Outpatient Cost to Charge Ratio of 52%","8.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.84;102% of Medicaid interim rate","11.28","75","","","Percent of Total Billed Charges","neg_dollar:$11.28","12.94","86","","","Percent of Total Billed Charges","neg_dollar:$12.94","10.53","70","","","Percent of Total Billed Charges","neg_dollar:$10.53","8.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.57;103.5% of Medicaid interim rate","15.05","150","","","Percent of Total Billed Charges","neg_dollar:$23.26;150% of Medicaid interim rate","12.04","80","","","Percent of Total Billed Charges","neg_dollar:$12.04;Percent of Total Billed Charges","13.84","92","","","Percent of Total Billed Charges","neg_dollar:$13.84","7.82","52","","","Percent of Total Billed Charges","neg_dollar:$7.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.82","52","","","Percent of Total Billed Charges","neg_dollar:$7.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","15.00",""
"MORPHINE SULFATE (PF) 10 MG/ML IV SOLN","J2270","HCPCS","00409-1893-03","NDC","636","RC","","Facility","Outpatient","1","ML","89.85","89.85","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","46.72","52","","","Percent of Total Billed Charges","neg_dollar:$46.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","77.27","86","","","Percent of Total Billed Charges","neg_dollar:$77.27","62.89","70","","","Percent of Total Billed Charges","neg_dollar:$62.89","46.72","52","","","Percent of Total Billed Charges","neg_dollar:$46.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.78;102% of Medicaid interim rate","67.38","75","","","Percent of Total Billed Charges","neg_dollar:$67.38","77.27","86","","","Percent of Total Billed Charges","neg_dollar:$77.27","62.89","70","","","Percent of Total Billed Charges","neg_dollar:$62.89","51.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.21;103.5% of Medicaid interim rate","89.85","150","","","Percent of Total Billed Charges","neg_dollar:$138.91;150% of Medicaid interim rate","71.88","80","","","Percent of Total Billed Charges","neg_dollar:$71.88;Percent of Total Billed Charges","82.66","92","","","Percent of Total Billed Charges","neg_dollar:$82.66","46.72","52","","","Percent of Total Billed Charges","neg_dollar:$46.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.72","52","","","Percent of Total Billed Charges","neg_dollar:$46.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","89.00",""
"MORPHINE 2 MG AND 4 MG IJ","J2270","HCPCS","76045-004-11","NDC","636","RC","","Facility","Outpatient","2","ML","90.40","90.40","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","47.00","52","","","Percent of Total Billed Charges","neg_dollar:$47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","77.74","86","","","Percent of Total Billed Charges","neg_dollar:$77.74","63.28","70","","","Percent of Total Billed Charges","neg_dollar:$63.28","47.00","52","","","Percent of Total Billed Charges","neg_dollar:$47;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.10;102% of Medicaid interim rate","67.80","75","","","Percent of Total Billed Charges","neg_dollar:$67.80","77.74","86","","","Percent of Total Billed Charges","neg_dollar:$77.74","63.28","70","","","Percent of Total Billed Charges","neg_dollar:$63.28","51.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.52;103.5% of Medicaid interim rate","90.40","150","","","Percent of Total Billed Charges","neg_dollar:$139.76;150% of Medicaid interim rate","72.32","80","","","Percent of Total Billed Charges","neg_dollar:$72.32;Percent of Total Billed Charges","83.16","92","","","Percent of Total Billed Charges","neg_dollar:$83.16","47.00","52","","","Percent of Total Billed Charges","neg_dollar:$47;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.00","52","","","Percent of Total Billed Charges","neg_dollar:$47;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","90.00",""
"MORPHINE SULFATE (PF) 2 MG/ML IV SOLN","J2270","HCPCS","00409-1890-01","NDC","250","RC","","Facility","Outpatient","1","ML","90.90","90.90","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","90.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.27","52","","","Percent of Total Billed Charges","neg_dollar:$47.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.27","52","","","Percent of Total Billed Charges","neg_dollar:$47.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.17","86","","","Percent of Total Billed Charges","neg_dollar:$78.17","63.63","70","","","Percent of Total Billed Charges","neg_dollar:$63.63","","52","","73.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.40;102% of Medicaid interim rate","68.17","75","","","Percent of Total Billed Charges","neg_dollar:$68.17","78.17","86","","","Percent of Total Billed Charges","neg_dollar:$78.17","63.63","70","","","Percent of Total Billed Charges","neg_dollar:$63.63","51.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.81;103.5% of Medicaid interim rate","90.90","150","","","Percent of Total Billed Charges","neg_dollar:$140.54;150% of Medicaid interim rate","72.72","80","","","Percent of Total Billed Charges","neg_dollar:$72.72;Percent of Total Billed Charges","83.63","92","","","Percent of Total Billed Charges","neg_dollar:$83.63","47.27","52","","","Percent of Total Billed Charges","neg_dollar:$47.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","90.00",""
"MORPHINE SULFATE (PF) 2 MG/ML IV SOLN","J2270","HCPCS","00409-1890-01","NDC","636","RC","","Facility","Outpatient","1","ML","90.92","90.92","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","47.28","52","","","Percent of Total Billed Charges","neg_dollar:$47.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.19","86","","","Percent of Total Billed Charges","neg_dollar:$78.19","63.64","70","","","Percent of Total Billed Charges","neg_dollar:$63.64","47.28","52","","","Percent of Total Billed Charges","neg_dollar:$47.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.41;102% of Medicaid interim rate","68.19","75","","","Percent of Total Billed Charges","neg_dollar:$68.19","78.19","86","","","Percent of Total Billed Charges","neg_dollar:$78.19","63.64","70","","","Percent of Total Billed Charges","neg_dollar:$63.64","51.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.82;103.5% of Medicaid interim rate","90.92","150","","","Percent of Total Billed Charges","neg_dollar:$140.57;150% of Medicaid interim rate","72.73","80","","","Percent of Total Billed Charges","neg_dollar:$72.73;Percent of Total Billed Charges","83.65","92","","","Percent of Total Billed Charges","neg_dollar:$83.65","47.28","52","","","Percent of Total Billed Charges","neg_dollar:$47.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.28","52","","","Percent of Total Billed Charges","neg_dollar:$47.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","90.00",""
"MORPHINE SULFATE (PF) 2 MG/ML IV SOLN","J2270","HCPCS","00409-1890-01","NDC","636","RC","","Facility","Outpatient","1","ML","91.80","91.80","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","47.73","52","","","Percent of Total Billed Charges","neg_dollar:$47.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.94","86","","","Percent of Total Billed Charges","neg_dollar:$78.94","64.25","70","","","Percent of Total Billed Charges","neg_dollar:$64.25","47.73","52","","","Percent of Total Billed Charges","neg_dollar:$47.73;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.93;102% of Medicaid interim rate","68.85","75","","","Percent of Total Billed Charges","neg_dollar:$68.85","78.94","86","","","Percent of Total Billed Charges","neg_dollar:$78.94","64.25","70","","","Percent of Total Billed Charges","neg_dollar:$64.25","52.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.32;103.5% of Medicaid interim rate","91.80","150","","","Percent of Total Billed Charges","neg_dollar:$141.92;150% of Medicaid interim rate","73.44","80","","","Percent of Total Billed Charges","neg_dollar:$73.44;Percent of Total Billed Charges","84.45","92","","","Percent of Total Billed Charges","neg_dollar:$84.45","47.73","52","","","Percent of Total Billed Charges","neg_dollar:$47.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.73","52","","","Percent of Total Billed Charges","neg_dollar:$47.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","91.00",""
"MORPHINE SULFATE (PF) 2 MG/ML IV SOLN","J2270","HCPCS","00409-1890-01","NDC","250","RC","","Facility","Outpatient","1","ML","90.72","90.72","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","90.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.17","52","","","Percent of Total Billed Charges","neg_dollar:$47.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.17","52","","","Percent of Total Billed Charges","neg_dollar:$47.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.02","86","","","Percent of Total Billed Charges","neg_dollar:$78.02","63.50","70","","","Percent of Total Billed Charges","neg_dollar:$63.50","","52","","73.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.30;102% of Medicaid interim rate","68.04","75","","","Percent of Total Billed Charges","neg_dollar:$68.04","78.02","86","","","Percent of Total Billed Charges","neg_dollar:$78.02","63.50","70","","","Percent of Total Billed Charges","neg_dollar:$63.50","51.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.71;103.5% of Medicaid interim rate","90.72","150","","","Percent of Total Billed Charges","neg_dollar:$140.26;150% of Medicaid interim rate","72.58","80","","","Percent of Total Billed Charges","neg_dollar:$72.58;Percent of Total Billed Charges","83.46","92","","","Percent of Total Billed Charges","neg_dollar:$83.46","47.17","52","","","Percent of Total Billed Charges","neg_dollar:$47.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","90.00",""
"MORPHINE SULFATE (PF) 2 MG/ML IV SOLN","J2270","HCPCS","00409-1890-01","NDC","250","RC","","Facility","Outpatient","1","ML","91.80","91.80","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","91.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.73","52","","","Percent of Total Billed Charges","neg_dollar:$47.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.73","52","","","Percent of Total Billed Charges","neg_dollar:$47.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.94","86","","","Percent of Total Billed Charges","neg_dollar:$78.94","64.25","70","","","Percent of Total Billed Charges","neg_dollar:$64.25","","52","","73.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.93;102% of Medicaid interim rate","68.85","75","","","Percent of Total Billed Charges","neg_dollar:$68.85","78.94","86","","","Percent of Total Billed Charges","neg_dollar:$78.94","64.25","70","","","Percent of Total Billed Charges","neg_dollar:$64.25","52.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.32;103.5% of Medicaid interim rate","91.80","150","","","Percent of Total Billed Charges","neg_dollar:$141.92;150% of Medicaid interim rate","73.44","80","","","Percent of Total Billed Charges","neg_dollar:$73.44;Percent of Total Billed Charges","84.45","92","","","Percent of Total Billed Charges","neg_dollar:$84.45","47.73","52","","","Percent of Total Billed Charges","neg_dollar:$47.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","91.00",""
"MORPHINE SULFATE (PF) 4 MG/ML IV SOLN","J2270","HCPCS","00409-1891-01","NDC","636","RC","","Facility","Outpatient","1","ML","90.42","90.42","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","47.02","52","","","Percent of Total Billed Charges","neg_dollar:$47.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","77.76","86","","","Percent of Total Billed Charges","neg_dollar:$77.76","63.29","70","","","Percent of Total Billed Charges","neg_dollar:$63.29","47.02","52","","","Percent of Total Billed Charges","neg_dollar:$47.02;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.12;102% of Medicaid interim rate","67.81","75","","","Percent of Total Billed Charges","neg_dollar:$67.81","77.76","86","","","Percent of Total Billed Charges","neg_dollar:$77.76","63.29","70","","","Percent of Total Billed Charges","neg_dollar:$63.29","51.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.54;103.5% of Medicaid interim rate","90.42","150","","","Percent of Total Billed Charges","neg_dollar:$139.80;150% of Medicaid interim rate","72.34","80","","","Percent of Total Billed Charges","neg_dollar:$72.34;Percent of Total Billed Charges","83.19","92","","","Percent of Total Billed Charges","neg_dollar:$83.19","47.02","52","","","Percent of Total Billed Charges","neg_dollar:$47.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.02","52","","","Percent of Total Billed Charges","neg_dollar:$47.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","90.00",""
"MORPHINE SULFATE (PF) 4 MG/ML IV SOLN","J2270","HCPCS","00409-1891-03","NDC","250","RC","","Facility","Outpatient","1","ML","91.40","91.40","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","91.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.52","52","","","Percent of Total Billed Charges","neg_dollar:$47.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.52","52","","","Percent of Total Billed Charges","neg_dollar:$47.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.60","86","","","Percent of Total Billed Charges","neg_dollar:$78.60","63.98","70","","","Percent of Total Billed Charges","neg_dollar:$63.98","","52","","73.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.69;102% of Medicaid interim rate","68.55","75","","","Percent of Total Billed Charges","neg_dollar:$68.55","78.60","86","","","Percent of Total Billed Charges","neg_dollar:$78.60","63.98","70","","","Percent of Total Billed Charges","neg_dollar:$63.98","52.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.09;103.5% of Medicaid interim rate","91.40","150","","","Percent of Total Billed Charges","neg_dollar:$141.30;150% of Medicaid interim rate","73.12","80","","","Percent of Total Billed Charges","neg_dollar:$73.12;Percent of Total Billed Charges","84.08","92","","","Percent of Total Billed Charges","neg_dollar:$84.08","47.52","52","","","Percent of Total Billed Charges","neg_dollar:$47.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","91.00",""
"MORPHINE SULFATE (PF) 4 MG/ML IV SOLN","J2270","HCPCS","00409-1891-01","NDC","250","RC","","Facility","Outpatient","1","ML","91.40","91.40","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","91.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.52","52","","","Percent of Total Billed Charges","neg_dollar:$47.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.52","52","","","Percent of Total Billed Charges","neg_dollar:$47.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.60","86","","","Percent of Total Billed Charges","neg_dollar:$78.60","63.98","70","","","Percent of Total Billed Charges","neg_dollar:$63.98","","52","","73.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.69;102% of Medicaid interim rate","68.55","75","","","Percent of Total Billed Charges","neg_dollar:$68.55","78.60","86","","","Percent of Total Billed Charges","neg_dollar:$78.60","63.98","70","","","Percent of Total Billed Charges","neg_dollar:$63.98","52.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.09;103.5% of Medicaid interim rate","91.40","150","","","Percent of Total Billed Charges","neg_dollar:$141.30;150% of Medicaid interim rate","73.12","80","","","Percent of Total Billed Charges","neg_dollar:$73.12;Percent of Total Billed Charges","84.08","92","","","Percent of Total Billed Charges","neg_dollar:$84.08","47.52","52","","","Percent of Total Billed Charges","neg_dollar:$47.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","91.00",""
"MORPHINE SULFATE (PF) 4 MG/ML IV SOLN","J2270","HCPCS","00409-1891-01","NDC","636","RC","","Facility","Outpatient","1","ML","89.45","89.45","","","","2.00","Fee Schedule","","","","","47.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","46.51","52","","","Percent of Total Billed Charges","neg_dollar:$46.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.92","86","","","Percent of Total Billed Charges","neg_dollar:$76.92","62.61","70","","","Percent of Total Billed Charges","neg_dollar:$62.61","46.51","52","","","Percent of Total Billed Charges","neg_dollar:$46.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.55;102% of Medicaid interim rate","67.08","75","","","Percent of Total Billed Charges","neg_dollar:$67.08","76.92","86","","","Percent of Total Billed Charges","neg_dollar:$76.92","62.61","70","","","Percent of Total Billed Charges","neg_dollar:$62.61","50.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.98;103.5% of Medicaid interim rate","89.45","150","","","Percent of Total Billed Charges","neg_dollar:$138.29;150% of Medicaid interim rate","71.56","80","","","Percent of Total Billed Charges","neg_dollar:$71.56;Percent of Total Billed Charges","82.29","92","","","Percent of Total Billed Charges","neg_dollar:$82.29","46.51","52","","","Percent of Total Billed Charges","neg_dollar:$46.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.51","52","","","Percent of Total Billed Charges","neg_dollar:$46.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","89.00",""
"MORPHINE SULFATE (PF) 10 MG/ML IV SOLN","J2272","HCPCS","63323-451-00","NDC","636","RC","","Facility","Outpatient","1","ML","89.35","89.35","","","","89.35","Fee Schedule","","","","","89.35","Fee Schedule","101% of Medicare Fee Schedule","","","","89.35","Fee Schedule","","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.84","86","","","Percent of Total Billed Charges","neg_dollar:$76.84","62.54","70","","","Percent of Total Billed Charges","neg_dollar:$62.54","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.49;102% of Medicaid interim rate","67.01","75","","","Percent of Total Billed Charges","neg_dollar:$67.01","76.84","86","","","Percent of Total Billed Charges","neg_dollar:$76.84","62.54","70","","","Percent of Total Billed Charges","neg_dollar:$62.54","50.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.92;103.5% of Medicaid interim rate","89.35","150","","","Percent of Total Billed Charges","neg_dollar:$138.13;150% of Medicaid interim rate","71.48","80","","","Percent of Total Billed Charges","neg_dollar:$71.48;Percent of Total Billed Charges","82.20","92","","","Percent of Total Billed Charges","neg_dollar:$82.20","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.00","89.00",""
"MORPHINE SULFATE (PF) 10 MG/ML IJ SOLN","J2272","HCPCS","63323-451-00","NDC","636","RC","","Facility","Outpatient","1","ML","93.60","93.60","","","","93.60","Fee Schedule","","","","","93.60","Fee Schedule","101% of Medicare Fee Schedule","","","","93.60","Fee Schedule","","48.67","52","","","Percent of Total Billed Charges","neg_dollar:$48.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","93.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","93.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","80.49","86","","","Percent of Total Billed Charges","neg_dollar:$80.49","65.52","70","","","Percent of Total Billed Charges","neg_dollar:$65.52","48.67","52","","","Percent of Total Billed Charges","neg_dollar:$48.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","54.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.98;102% of Medicaid interim rate","70.19","75","","","Percent of Total Billed Charges","neg_dollar:$70.19","80.49","86","","","Percent of Total Billed Charges","neg_dollar:$80.49","65.52","70","","","Percent of Total Billed Charges","neg_dollar:$65.52","53.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.35;103.5% of Medicaid interim rate","93.60","150","","","Percent of Total Billed Charges","neg_dollar:$144.71;150% of Medicaid interim rate","74.88","80","","","Percent of Total Billed Charges","neg_dollar:$74.88;Percent of Total Billed Charges","86.11","92","","","Percent of Total Billed Charges","neg_dollar:$86.11","48.67","52","","","Percent of Total Billed Charges","neg_dollar:$48.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.67","52","","","Percent of Total Billed Charges","neg_dollar:$48.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.00","93.00",""
"MORPHINE SULFATE (PF) 10 MG/ML IV SOLN","J2272","HCPCS","63323-451-00","NDC","250","RC","","Facility","Outpatient","1","ML","90.55","90.55","","","","90.55","Fee Schedule","","","","","90.55","Fee Schedule","","","","","90.55","Fee Schedule","","","52","","90.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.08","52","","","Percent of Total Billed Charges","neg_dollar:$47.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.08","52","","","Percent of Total Billed Charges","neg_dollar:$47.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","77.87","86","","","Percent of Total Billed Charges","neg_dollar:$77.87","63.38","70","","","Percent of Total Billed Charges","neg_dollar:$63.38","","52","","90.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.19;102% of Medicaid interim rate","67.91","75","","","Percent of Total Billed Charges","neg_dollar:$67.91","77.87","86","","","Percent of Total Billed Charges","neg_dollar:$77.87","63.38","70","","","Percent of Total Billed Charges","neg_dollar:$63.38","51.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.61;103.5% of Medicaid interim rate","90.55","150","","","Percent of Total Billed Charges","neg_dollar:$139.99;150% of Medicaid interim rate","72.44","80","","","Percent of Total Billed Charges","neg_dollar:$72.44;Percent of Total Billed Charges","83.30","92","","","Percent of Total Billed Charges","neg_dollar:$83.30","47.08","52","","","Percent of Total Billed Charges","neg_dollar:$47.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","90.55","Fee Schedule","","47.00","90.00",""
"NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN","J2305","HCPCS","00338-1047-02","NDC","636","RC","","Facility","Outpatient","1","ML","25.70","25.70","","","","25.70","Fee Schedule","","","","","25.70","Fee Schedule","101% of Medicare Fee Schedule","","","","25.70","Fee Schedule","","13.36","52","","","Percent of Total Billed Charges","neg_dollar:$13.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.10","86","","","Percent of Total Billed Charges","neg_dollar:$22.10","17.99","70","","","Percent of Total Billed Charges","neg_dollar:$17.99","13.36","52","","","Percent of Total Billed Charges","neg_dollar:$13.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","15.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.09;102% of Medicaid interim rate","19.27","75","","","Percent of Total Billed Charges","neg_dollar:$19.27","22.10","86","","","Percent of Total Billed Charges","neg_dollar:$22.10","17.99","70","","","Percent of Total Billed Charges","neg_dollar:$17.99","14.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.64;103.5% of Medicaid interim rate","25.70","150","","","Percent of Total Billed Charges","neg_dollar:$39.73;150% of Medicaid interim rate","20.56","80","","","Percent of Total Billed Charges","neg_dollar:$20.56;Percent of Total Billed Charges","23.64","92","","","Percent of Total Billed Charges","neg_dollar:$23.64","13.36","52","","","Percent of Total Billed Charges","neg_dollar:$13.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.36","52","","","Percent of Total Billed Charges","neg_dollar:$13.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","25.00",""
"NALOXONE HCL 0.4 MG/ML WRAPPER","J2310","HCPCS","00409-1215-01","NDC","636","RC","","Facility","Outpatient","1","EA","119.20","119.20","","","","39.00","Fee Schedule","","","","","55.00","Fee Schedule","101% of Medicare Fee Schedule","","","","13.00","Fee Schedule","","61.98","52","","","Percent of Total Billed Charges","neg_dollar:$61.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","119.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","119.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","102.51","86","","","Percent of Total Billed Charges","neg_dollar:$102.51","83.44","70","","","Percent of Total Billed Charges","neg_dollar:$83.44","61.98","52","","","Percent of Total Billed Charges","neg_dollar:$61.98;105% Medicare Outpatient Cost to Charge Ratio of 52%","70.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$70.02;102% of Medicaid interim rate","89.40","75","","","Percent of Total Billed Charges","neg_dollar:$89.40","102.51","86","","","Percent of Total Billed Charges","neg_dollar:$102.51","83.44","70","","","Percent of Total Billed Charges","neg_dollar:$83.44","67.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$67.94;103.5% of Medicaid interim rate","119.20","150","","","Percent of Total Billed Charges","neg_dollar:$184.28;150% of Medicaid interim rate","95.36","80","","","Percent of Total Billed Charges","neg_dollar:$95.36;Percent of Total Billed Charges","109.66","92","","","Percent of Total Billed Charges","neg_dollar:$109.66","61.98","52","","","Percent of Total Billed Charges","neg_dollar:$61.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","61.98","52","","","Percent of Total Billed Charges","neg_dollar:$61.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","119.00",""
"NALOXONE HCL 2 MG/2ML IJ SOSY","J2310","HCPCS","76329-3369-1","NDC","636","RC","","Facility","Outpatient","2","ML","76.75","76.75","","","","39.00","Fee Schedule","","","","","55.00","Fee Schedule","101% of Medicare Fee Schedule","","","","13.00","Fee Schedule","","39.91","52","","","Percent of Total Billed Charges","neg_dollar:$39.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","76.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","76.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","66.00","86","","","Percent of Total Billed Charges","neg_dollar:$66","53.72","70","","","Percent of Total Billed Charges","neg_dollar:$53.72","39.91","52","","","Percent of Total Billed Charges","neg_dollar:$39.91;105% Medicare Outpatient Cost to Charge Ratio of 52%","45.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$45.09;102% of Medicaid interim rate","57.56","75","","","Percent of Total Billed Charges","neg_dollar:$57.56","66.00","86","","","Percent of Total Billed Charges","neg_dollar:$66","53.72","70","","","Percent of Total Billed Charges","neg_dollar:$53.72","43.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$43.74;103.5% of Medicaid interim rate","76.75","150","","","Percent of Total Billed Charges","neg_dollar:$118.65;150% of Medicaid interim rate","61.40","80","","","Percent of Total Billed Charges","neg_dollar:$61.40;Percent of Total Billed Charges","70.61","92","","","Percent of Total Billed Charges","neg_dollar:$70.61","39.91","52","","","Percent of Total Billed Charges","neg_dollar:$39.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","39.91","52","","","Percent of Total Billed Charges","neg_dollar:$39.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","76.00",""
"OCRELIZUMAB 300 MG/10ML IV SOLN","J2350","HCPCS","50242-150-01","NDC","636","RC","","Facility","Outpatient","10","ML","131.57","131.57","","","","131.57","Fee Schedule","","","","","131.57","Fee Schedule","101% of Medicare Fee Schedule","","","","131.57","Fee Schedule","","68.41","52","","","Percent of Total Billed Charges","neg_dollar:$68.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","131.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","131.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","113.15","86","","","Percent of Total Billed Charges","neg_dollar:$113.15","92.10","70","","","Percent of Total Billed Charges","neg_dollar:$92.10","68.41","52","","","Percent of Total Billed Charges","neg_dollar:$68.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","77.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$77.30;102% of Medicaid interim rate","98.68","75","","","Percent of Total Billed Charges","neg_dollar:$98.68","113.15","86","","","Percent of Total Billed Charges","neg_dollar:$113.15","92.10","70","","","Percent of Total Billed Charges","neg_dollar:$92.10","74.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$74.99;103.5% of Medicaid interim rate","131.57","150","","","Percent of Total Billed Charges","neg_dollar:$203.42;150% of Medicaid interim rate","105.26","80","","","Percent of Total Billed Charges","neg_dollar:$105.26;Percent of Total Billed Charges","121.04","92","","","Percent of Total Billed Charges","neg_dollar:$121.04","68.41","52","","","Percent of Total Billed Charges","neg_dollar:$68.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","68.41","52","","","Percent of Total Billed Charges","neg_dollar:$68.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","68.00","131.00",""
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","J2371","HCPCS","00641-6142-25","NDC","636","RC","","Facility","Outpatient","10","ML","0.19","0.19","","","","0.19","Fee Schedule","","","","","0.19","Fee Schedule","101% of Medicare Fee Schedule","","","","0.19","Fee Schedule","","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.19","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.19","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.16","86","","","Percent of Total Billed Charges","neg_dollar:$0.16","0.13","70","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.11;102% of Medicaid interim rate","0.14","75","","","Percent of Total Billed Charges","neg_dollar:$0.14","0.16","86","","","Percent of Total Billed Charges","neg_dollar:$0.16","0.13","70","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.10;103.5% of Medicaid interim rate","0.19","150","","","Percent of Total Billed Charges","neg_dollar:$0.29;150% of Medicaid interim rate","0.15","80","","","Percent of Total Billed Charges","neg_dollar:$0.15;Percent of Total Billed Charges","0.17","92","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","J2371","HCPCS","55150-300-25","NDC","636","RC","","Facility","Outpatient","10","ML","0.18","0.18","","","","0.18","Fee Schedule","","","","","0.18","Fee Schedule","101% of Medicare Fee Schedule","","","","0.18","Fee Schedule","","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.16","86","","","Percent of Total Billed Charges","neg_dollar:$0.16","0.13","70","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.11;102% of Medicaid interim rate","0.14","75","","","Percent of Total Billed Charges","neg_dollar:$0.14","0.16","86","","","Percent of Total Billed Charges","neg_dollar:$0.16","0.13","70","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.10;103.5% of Medicaid interim rate","0.18","150","","","Percent of Total Billed Charges","neg_dollar:$0.29;150% of Medicaid interim rate","0.15","80","","","Percent of Total Billed Charges","neg_dollar:$0.15;Percent of Total Billed Charges","0.17","92","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.09","52","","","Percent of Total Billed Charges","neg_dollar:$0.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PHENYLEPHRINE HCL (PRESSORS) 10 MG/ML IV SOLN","J2371","HCPCS","00641-6142-25","NDC","636","RC","","Facility","Outpatient","10","ML","4.39","4.39","","","","4.39","Fee Schedule","","","","","4.39","Fee Schedule","101% of Medicare Fee Schedule","","","","4.39","Fee Schedule","","2.28","52","","","Percent of Total Billed Charges","neg_dollar:$2.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.39","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.39","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.77","86","","","Percent of Total Billed Charges","neg_dollar:$3.77","3.07","70","","","Percent of Total Billed Charges","neg_dollar:$3.07","2.28","52","","","Percent of Total Billed Charges","neg_dollar:$2.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.58;102% of Medicaid interim rate","3.29","75","","","Percent of Total Billed Charges","neg_dollar:$3.29","3.77","86","","","Percent of Total Billed Charges","neg_dollar:$3.77","3.07","70","","","Percent of Total Billed Charges","neg_dollar:$3.07","2.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.50;103.5% of Medicaid interim rate","4.39","150","","","Percent of Total Billed Charges","neg_dollar:$6.79;150% of Medicaid interim rate","3.51","80","","","Percent of Total Billed Charges","neg_dollar:$3.51;Percent of Total Billed Charges","4.04","92","","","Percent of Total Billed Charges","neg_dollar:$4.04","2.28","52","","","Percent of Total Billed Charges","neg_dollar:$2.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.28","52","","","Percent of Total Billed Charges","neg_dollar:$2.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","J2405","HCPCS","60505-6130-5","NDC","250","RC","","Facility","Outpatient","2","ML","22.11","22.11","","","","22.11","Fee Schedule","","","","","22.11","Fee Schedule","","","","","22.11","Fee Schedule","","","52","","22.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.49","52","","","Percent of Total Billed Charges","neg_dollar:$11.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.49","52","","","Percent of Total Billed Charges","neg_dollar:$11.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.01","86","","","Percent of Total Billed Charges","neg_dollar:$19.01","15.47","70","","","Percent of Total Billed Charges","neg_dollar:$15.47","","52","","22.11","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","12.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.99;102% of Medicaid interim rate","16.58","75","","","Percent of Total Billed Charges","neg_dollar:$16.58","19.01","86","","","Percent of Total Billed Charges","neg_dollar:$19.01","15.47","70","","","Percent of Total Billed Charges","neg_dollar:$15.47","12.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.60;103.5% of Medicaid interim rate","22.11","150","","","Percent of Total Billed Charges","neg_dollar:$34.18;150% of Medicaid interim rate","17.69","80","","","Percent of Total Billed Charges","neg_dollar:$17.69;Percent of Total Billed Charges","20.34","92","","","Percent of Total Billed Charges","neg_dollar:$20.34","11.49","52","","","Percent of Total Billed Charges","neg_dollar:$11.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","22.11","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","11.00","22.00",""
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","J2405","HCPCS","60505-6130-0","NDC","636","RC","","Facility","Outpatient","2","ML","21.77","21.77","","","","21.77","Fee Schedule","","","","","21.77","Fee Schedule","101% of Medicare Fee Schedule","","","","21.77","Fee Schedule","","11.32","52","","","Percent of Total Billed Charges","neg_dollar:$11.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","21.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","21.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","18.72","86","","","Percent of Total Billed Charges","neg_dollar:$18.72","15.23","70","","","Percent of Total Billed Charges","neg_dollar:$15.23","11.32","52","","","Percent of Total Billed Charges","neg_dollar:$11.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","12.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.79;102% of Medicaid interim rate","16.32","75","","","Percent of Total Billed Charges","neg_dollar:$16.32","18.72","86","","","Percent of Total Billed Charges","neg_dollar:$18.72","15.23","70","","","Percent of Total Billed Charges","neg_dollar:$15.23","12.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.40;103.5% of Medicaid interim rate","21.77","150","","","Percent of Total Billed Charges","neg_dollar:$33.65;150% of Medicaid interim rate","17.41","80","","","Percent of Total Billed Charges","neg_dollar:$17.41;Percent of Total Billed Charges","20.02","92","","","Percent of Total Billed Charges","neg_dollar:$20.02","11.32","52","","","Percent of Total Billed Charges","neg_dollar:$11.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.32","52","","","Percent of Total Billed Charges","neg_dollar:$11.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.00","21.00",""
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","J2405","HCPCS","60505-6130-0","NDC","250","RC","","Facility","Outpatient","2","ML","21.67","21.67","","","","21.67","Fee Schedule","","","","","21.67","Fee Schedule","","","","","21.67","Fee Schedule","","","52","","21.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.27","52","","","Percent of Total Billed Charges","neg_dollar:$11.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.27","52","","","Percent of Total Billed Charges","neg_dollar:$11.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.64","86","","","Percent of Total Billed Charges","neg_dollar:$18.64","15.17","70","","","Percent of Total Billed Charges","neg_dollar:$15.17","","52","","21.67","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","12.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.73;102% of Medicaid interim rate","16.25","75","","","Percent of Total Billed Charges","neg_dollar:$16.25","18.64","86","","","Percent of Total Billed Charges","neg_dollar:$18.64","15.17","70","","","Percent of Total Billed Charges","neg_dollar:$15.17","12.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.35;103.5% of Medicaid interim rate","21.67","150","","","Percent of Total Billed Charges","neg_dollar:$33.51;150% of Medicaid interim rate","17.33","80","","","Percent of Total Billed Charges","neg_dollar:$17.33;Percent of Total Billed Charges","19.94","92","","","Percent of Total Billed Charges","neg_dollar:$19.94","11.27","52","","","Percent of Total Billed Charges","neg_dollar:$11.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","21.67","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","11.00","21.00",""
"ONDANSETRON HCL 4 MG/2ML IJ SOLN","J2405","HCPCS","60505-6130-5","NDC","636","RC","","Facility","Outpatient","2","ML","22.11","22.11","","","","22.11","Fee Schedule","","","","","22.11","Fee Schedule","101% of Medicare Fee Schedule","","","","22.11","Fee Schedule","","11.49","52","","","Percent of Total Billed Charges","neg_dollar:$11.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","22.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","22.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","19.01","86","","","Percent of Total Billed Charges","neg_dollar:$19.01","15.47","70","","","Percent of Total Billed Charges","neg_dollar:$15.47","11.49","52","","","Percent of Total Billed Charges","neg_dollar:$11.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","12.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.99;102% of Medicaid interim rate","16.58","75","","","Percent of Total Billed Charges","neg_dollar:$16.58","19.01","86","","","Percent of Total Billed Charges","neg_dollar:$19.01","15.47","70","","","Percent of Total Billed Charges","neg_dollar:$15.47","12.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.60;103.5% of Medicaid interim rate","22.11","150","","","Percent of Total Billed Charges","neg_dollar:$34.18;150% of Medicaid interim rate","17.69","80","","","Percent of Total Billed Charges","neg_dollar:$17.69;Percent of Total Billed Charges","20.34","92","","","Percent of Total Billed Charges","neg_dollar:$20.34","11.49","52","","","Percent of Total Billed Charges","neg_dollar:$11.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.49","52","","","Percent of Total Billed Charges","neg_dollar:$11.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.00","22.00",""
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","J2470","HCPCS","00008-0923-51","NDC","636","RC","","Facility","Outpatient","1","UN","90.78","90.78","","","","90.78","Fee Schedule","","","","","90.78","Fee Schedule","101% of Medicare Fee Schedule","","","","90.78","Fee Schedule","","47.20","52","","","Percent of Total Billed Charges","neg_dollar:$47.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.78","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.78","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.07","86","","","Percent of Total Billed Charges","neg_dollar:$78.07","63.55","70","","","Percent of Total Billed Charges","neg_dollar:$63.55","47.20","52","","","Percent of Total Billed Charges","neg_dollar:$47.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.33;102% of Medicaid interim rate","68.09","75","","","Percent of Total Billed Charges","neg_dollar:$68.09","78.07","86","","","Percent of Total Billed Charges","neg_dollar:$78.07","63.55","70","","","Percent of Total Billed Charges","neg_dollar:$63.55","51.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.74;103.5% of Medicaid interim rate","90.78","150","","","Percent of Total Billed Charges","neg_dollar:$140.36;150% of Medicaid interim rate","72.63","80","","","Percent of Total Billed Charges","neg_dollar:$72.63;Percent of Total Billed Charges","83.52","92","","","Percent of Total Billed Charges","neg_dollar:$83.52","47.20","52","","","Percent of Total Billed Charges","neg_dollar:$47.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.20","52","","","Percent of Total Billed Charges","neg_dollar:$47.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.00","90.00",""
"PANTOPRAZOLE SODIUM 40 MG IV SOLR","J2470","HCPCS","00008-0923-51","NDC","250","RC","","Facility","Outpatient","1","UN","97.57","97.57","","","","97.57","Fee Schedule","","","","","97.57","Fee Schedule","","","","","97.57","Fee Schedule","","","52","","97.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","50.74","52","","","Percent of Total Billed Charges","neg_dollar:$50.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.74","52","","","Percent of Total Billed Charges","neg_dollar:$50.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.91","86","","","Percent of Total Billed Charges","neg_dollar:$83.91","68.30","70","","","Percent of Total Billed Charges","neg_dollar:$68.30","","52","","97.57","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","57.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.32;102% of Medicaid interim rate","73.18","75","","","Percent of Total Billed Charges","neg_dollar:$73.18","83.91","86","","","Percent of Total Billed Charges","neg_dollar:$83.91","68.30","70","","","Percent of Total Billed Charges","neg_dollar:$68.30","55.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.61;103.5% of Medicaid interim rate","97.57","150","","","Percent of Total Billed Charges","neg_dollar:$150.86;150% of Medicaid interim rate","78.06","80","","","Percent of Total Billed Charges","neg_dollar:$78.06;Percent of Total Billed Charges","89.77","92","","","Percent of Total Billed Charges","neg_dollar:$89.77","50.74","52","","","Percent of Total Billed Charges","neg_dollar:$50.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","97.57","Fee Schedule","","50.00","97.00",""
"PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR","J2540","HCPCS","00049-0520-83","NDC","250","RC","","Facility","Outpatient","1","EA","13.67","13.67","","","","13.67","Fee Schedule","","","","","13.67","Fee Schedule","","","","","13.67","Fee Schedule","","","52","","13.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.10","52","","","Percent of Total Billed Charges","neg_dollar:$7.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.10","52","","","Percent of Total Billed Charges","neg_dollar:$7.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.75","86","","","Percent of Total Billed Charges","neg_dollar:$11.75","9.56","70","","","Percent of Total Billed Charges","neg_dollar:$9.56","","52","","13.67","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.03;102% of Medicaid interim rate","10.25","75","","","Percent of Total Billed Charges","neg_dollar:$10.25","11.75","86","","","Percent of Total Billed Charges","neg_dollar:$11.75","9.56","70","","","Percent of Total Billed Charges","neg_dollar:$9.56","7.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.79;103.5% of Medicaid interim rate","13.67","150","","","Percent of Total Billed Charges","neg_dollar:$21.13;150% of Medicaid interim rate","10.93","80","","","Percent of Total Billed Charges","neg_dollar:$10.93;Percent of Total Billed Charges","12.57","92","","","Percent of Total Billed Charges","neg_dollar:$12.57","7.10","52","","","Percent of Total Billed Charges","neg_dollar:$7.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","13.67","Fee Schedule","","7.00","13.00",""
"PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR","J2540","HCPCS","00049-0520-84","NDC","250","RC","","Facility","Outpatient","1","EA","13.67","13.67","","","","13.67","Fee Schedule","","","","","13.67","Fee Schedule","","","","","13.67","Fee Schedule","","","52","","13.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.10","52","","","Percent of Total Billed Charges","neg_dollar:$7.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.10","52","","","Percent of Total Billed Charges","neg_dollar:$7.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.75","86","","","Percent of Total Billed Charges","neg_dollar:$11.75","9.56","70","","","Percent of Total Billed Charges","neg_dollar:$9.56","","52","","13.67","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.03;102% of Medicaid interim rate","10.25","75","","","Percent of Total Billed Charges","neg_dollar:$10.25","11.75","86","","","Percent of Total Billed Charges","neg_dollar:$11.75","9.56","70","","","Percent of Total Billed Charges","neg_dollar:$9.56","7.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.79;103.5% of Medicaid interim rate","13.67","150","","","Percent of Total Billed Charges","neg_dollar:$21.13;150% of Medicaid interim rate","10.93","80","","","Percent of Total Billed Charges","neg_dollar:$10.93;Percent of Total Billed Charges","12.57","92","","","Percent of Total Billed Charges","neg_dollar:$12.57","7.10","52","","","Percent of Total Billed Charges","neg_dollar:$7.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","13.67","Fee Schedule","","7.00","13.00",""
"PIPERACILLIN TAZOBACTAM 2-0.25 G IV SOLR","J2543","HCPCS","55150-119-30","NDC","636","RC","","Facility","Outpatient","1","EA","46.86","46.86","","","","36.00","Fee Schedule","","","","","46.86","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","24.36","52","","","Percent of Total Billed Charges","neg_dollar:$24.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","46.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","46.86","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","40.30","86","","","Percent of Total Billed Charges","neg_dollar:$40.30","32.80","70","","","Percent of Total Billed Charges","neg_dollar:$32.80","24.36","52","","","Percent of Total Billed Charges","neg_dollar:$24.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","27.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.53;102% of Medicaid interim rate","35.14","75","","","Percent of Total Billed Charges","neg_dollar:$35.14","40.30","86","","","Percent of Total Billed Charges","neg_dollar:$40.30","32.80","70","","","Percent of Total Billed Charges","neg_dollar:$32.80","26.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.71;103.5% of Medicaid interim rate","46.86","150","","","Percent of Total Billed Charges","neg_dollar:$72.45;150% of Medicaid interim rate","37.49","80","","","Percent of Total Billed Charges","neg_dollar:$37.49;Percent of Total Billed Charges","43.11","92","","","Percent of Total Billed Charges","neg_dollar:$43.11","24.36","52","","","Percent of Total Billed Charges","neg_dollar:$24.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","24.36","52","","","Percent of Total Billed Charges","neg_dollar:$24.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","46.00",""
"PIPERACILLIN TAZOBACTAM 2-0.25 G IV SOLR","J2543","HCPCS","60505-6156-0","NDC","636","RC","","Facility","Outpatient","1","EA","47.25","47.25","","","","36.00","Fee Schedule","","","","","47.25","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","24.57","52","","","Percent of Total Billed Charges","neg_dollar:$24.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","47.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","47.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","40.63","86","","","Percent of Total Billed Charges","neg_dollar:$40.63","33.07","70","","","Percent of Total Billed Charges","neg_dollar:$33.07","24.57","52","","","Percent of Total Billed Charges","neg_dollar:$24.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","27.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.75;102% of Medicaid interim rate","35.43","75","","","Percent of Total Billed Charges","neg_dollar:$35.43","40.63","86","","","Percent of Total Billed Charges","neg_dollar:$40.63","33.07","70","","","Percent of Total Billed Charges","neg_dollar:$33.07","26.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.93;103.5% of Medicaid interim rate","47.25","150","","","Percent of Total Billed Charges","neg_dollar:$73.05;150% of Medicaid interim rate","37.80","80","","","Percent of Total Billed Charges","neg_dollar:$37.80;Percent of Total Billed Charges","43.47","92","","","Percent of Total Billed Charges","neg_dollar:$43.47","24.57","52","","","Percent of Total Billed Charges","neg_dollar:$24.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","24.57","52","","","Percent of Total Billed Charges","neg_dollar:$24.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","47.00",""
"PIPERACILLIN TAZOBACTAM 2-0.25 G IV SOLR","J2543","HCPCS","55150-119-30","NDC","250","RC","","Facility","Outpatient","1","EA","42.32","42.32","","","","36.00","Fee Schedule","","","","","42.32","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","42.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.00","52","","","Percent of Total Billed Charges","neg_dollar:$22;102% Medicare Outpatient Cost to Charge Ratio of 52%","22.00","52","","","Percent of Total Billed Charges","neg_dollar:$22;102% Medicare Outpatient Cost to Charge Ratio of 52%","36.39","86","","","Percent of Total Billed Charges","neg_dollar:$36.39","29.62","70","","","Percent of Total Billed Charges","neg_dollar:$29.62","","52","","42.32","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","24.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.86;102% of Medicaid interim rate","31.74","75","","","Percent of Total Billed Charges","neg_dollar:$31.74","36.39","86","","","Percent of Total Billed Charges","neg_dollar:$36.39","29.62","70","","","Percent of Total Billed Charges","neg_dollar:$29.62","24.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.12;103.5% of Medicaid interim rate","42.32","150","","","Percent of Total Billed Charges","neg_dollar:$65.43;150% of Medicaid interim rate","33.85","80","","","Percent of Total Billed Charges","neg_dollar:$33.85;Percent of Total Billed Charges","38.93","92","","","Percent of Total Billed Charges","neg_dollar:$38.93","22.00","52","","","Percent of Total Billed Charges","neg_dollar:$22;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","42.32","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","42.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR","J2543","HCPCS","55150-120-30","NDC","250","RC","","Facility","Outpatient","1","EA","32.91","32.91","","","","32.91","Fee Schedule","","","","","32.91","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","32.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.11","52","","","Percent of Total Billed Charges","neg_dollar:$17.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.11","52","","","Percent of Total Billed Charges","neg_dollar:$17.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.30","86","","","Percent of Total Billed Charges","neg_dollar:$28.30","23.03","70","","","Percent of Total Billed Charges","neg_dollar:$23.03","","52","","32.91","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","19.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.33;102% of Medicaid interim rate","24.68","75","","","Percent of Total Billed Charges","neg_dollar:$24.68","28.30","86","","","Percent of Total Billed Charges","neg_dollar:$28.30","23.03","70","","","Percent of Total Billed Charges","neg_dollar:$23.03","18.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.75;103.5% of Medicaid interim rate","32.91","150","","","Percent of Total Billed Charges","neg_dollar:$50.88;150% of Medicaid interim rate","26.32","80","","","Percent of Total Billed Charges","neg_dollar:$26.32;Percent of Total Billed Charges","30.27","92","","","Percent of Total Billed Charges","neg_dollar:$30.27","17.11","52","","","Percent of Total Billed Charges","neg_dollar:$17.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","32.91","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","32.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR","J2543","HCPCS","65219-436-02","NDC","636","RC","","Facility","Outpatient","1","EA","31.83","31.83","","","","31.83","Fee Schedule","","","","","31.83","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","16.55","52","","","Percent of Total Billed Charges","neg_dollar:$16.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","27.37","86","","","Percent of Total Billed Charges","neg_dollar:$27.37","22.28","70","","","Percent of Total Billed Charges","neg_dollar:$22.28","16.55","52","","","Percent of Total Billed Charges","neg_dollar:$16.55;105% Medicare Outpatient Cost to Charge Ratio of 52%","18.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.70;102% of Medicaid interim rate","23.87","75","","","Percent of Total Billed Charges","neg_dollar:$23.87","27.37","86","","","Percent of Total Billed Charges","neg_dollar:$27.37","22.28","70","","","Percent of Total Billed Charges","neg_dollar:$22.28","18.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.14;103.5% of Medicaid interim rate","31.83","150","","","Percent of Total Billed Charges","neg_dollar:$49.21;150% of Medicaid interim rate","25.46","80","","","Percent of Total Billed Charges","neg_dollar:$25.46;Percent of Total Billed Charges","29.28","92","","","Percent of Total Billed Charges","neg_dollar:$29.28","16.55","52","","","Percent of Total Billed Charges","neg_dollar:$16.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.55","52","","","Percent of Total Billed Charges","neg_dollar:$16.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","31.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR","J2543","HCPCS","60505-6157-0","NDC","636","RC","","Facility","Outpatient","1","EA","31.50","31.50","","","","31.50","Fee Schedule","","","","","31.50","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","16.38","52","","","Percent of Total Billed Charges","neg_dollar:$16.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","27.09","86","","","Percent of Total Billed Charges","neg_dollar:$27.09","22.04","70","","","Percent of Total Billed Charges","neg_dollar:$22.04","16.38","52","","","Percent of Total Billed Charges","neg_dollar:$16.38;105% Medicare Outpatient Cost to Charge Ratio of 52%","18.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.50;102% of Medicaid interim rate","23.62","75","","","Percent of Total Billed Charges","neg_dollar:$23.62","27.09","86","","","Percent of Total Billed Charges","neg_dollar:$27.09","22.04","70","","","Percent of Total Billed Charges","neg_dollar:$22.04","17.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.95;103.5% of Medicaid interim rate","31.50","150","","","Percent of Total Billed Charges","neg_dollar:$48.70;150% of Medicaid interim rate","25.20","80","","","Percent of Total Billed Charges","neg_dollar:$25.20;Percent of Total Billed Charges","28.98","92","","","Percent of Total Billed Charges","neg_dollar:$28.98","16.38","52","","","Percent of Total Billed Charges","neg_dollar:$16.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.38","52","","","Percent of Total Billed Charges","neg_dollar:$16.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","31.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR","J2543","HCPCS","55150-120-30","NDC","636","RC","","Facility","Outpatient","1","EA","32.83","32.83","","","","32.83","Fee Schedule","","","","","32.83","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","17.07","52","","","Percent of Total Billed Charges","neg_dollar:$17.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","32.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","32.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.23","86","","","Percent of Total Billed Charges","neg_dollar:$28.23","22.98","70","","","Percent of Total Billed Charges","neg_dollar:$22.98","17.07","52","","","Percent of Total Billed Charges","neg_dollar:$17.07;105% Medicare Outpatient Cost to Charge Ratio of 52%","19.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.28;102% of Medicaid interim rate","24.62","75","","","Percent of Total Billed Charges","neg_dollar:$24.62","28.23","86","","","Percent of Total Billed Charges","neg_dollar:$28.23","22.98","70","","","Percent of Total Billed Charges","neg_dollar:$22.98","18.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.71;103.5% of Medicaid interim rate","32.83","150","","","Percent of Total Billed Charges","neg_dollar:$50.76;150% of Medicaid interim rate","26.26","80","","","Percent of Total Billed Charges","neg_dollar:$26.26;Percent of Total Billed Charges","30.20","92","","","Percent of Total Billed Charges","neg_dollar:$30.20","17.07","52","","","Percent of Total Billed Charges","neg_dollar:$17.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","17.07","52","","","Percent of Total Billed Charges","neg_dollar:$17.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","32.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR","J2543","HCPCS","60505-6157-0","NDC","250","RC","","Facility","Outpatient","1","EA","31.50","31.50","","","","31.50","Fee Schedule","","","","","31.50","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","31.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.38","52","","","Percent of Total Billed Charges","neg_dollar:$16.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.38","52","","","Percent of Total Billed Charges","neg_dollar:$16.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.09","86","","","Percent of Total Billed Charges","neg_dollar:$27.09","22.04","70","","","Percent of Total Billed Charges","neg_dollar:$22.04","","52","","31.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","18.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.50;102% of Medicaid interim rate","23.62","75","","","Percent of Total Billed Charges","neg_dollar:$23.62","27.09","86","","","Percent of Total Billed Charges","neg_dollar:$27.09","22.04","70","","","Percent of Total Billed Charges","neg_dollar:$22.04","17.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.95;103.5% of Medicaid interim rate","31.50","150","","","Percent of Total Billed Charges","neg_dollar:$48.70;150% of Medicaid interim rate","25.20","80","","","Percent of Total Billed Charges","neg_dollar:$25.20;Percent of Total Billed Charges","28.98","92","","","Percent of Total Billed Charges","neg_dollar:$28.98","16.38","52","","","Percent of Total Billed Charges","neg_dollar:$16.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","31.50","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","31.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR","J2543","HCPCS","65219-436-02","NDC","250","RC","","Facility","Outpatient","1","EA","31.83","31.83","","","","31.83","Fee Schedule","","","","","31.83","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","31.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.55","52","","","Percent of Total Billed Charges","neg_dollar:$16.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.55","52","","","Percent of Total Billed Charges","neg_dollar:$16.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.37","86","","","Percent of Total Billed Charges","neg_dollar:$27.37","22.28","70","","","Percent of Total Billed Charges","neg_dollar:$22.28","","52","","31.83","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","18.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.70;102% of Medicaid interim rate","23.87","75","","","Percent of Total Billed Charges","neg_dollar:$23.87","27.37","86","","","Percent of Total Billed Charges","neg_dollar:$27.37","22.28","70","","","Percent of Total Billed Charges","neg_dollar:$22.28","18.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.14;103.5% of Medicaid interim rate","31.83","150","","","Percent of Total Billed Charges","neg_dollar:$49.21;150% of Medicaid interim rate","25.46","80","","","Percent of Total Billed Charges","neg_dollar:$25.46;Percent of Total Billed Charges","29.28","92","","","Percent of Total Billed Charges","neg_dollar:$29.28","16.55","52","","","Percent of Total Billed Charges","neg_dollar:$16.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","31.83","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","31.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR","J2543","HCPCS","60505-6159-4","NDC","250","RC","","Facility","Outpatient","1","EA","25.12","25.12","","","","25.12","Fee Schedule","","","","","25.12","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","25.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","","52","","25.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.76;102% of Medicaid interim rate","18.84","75","","","Percent of Total Billed Charges","neg_dollar:$18.84","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","14.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.32;103.5% of Medicaid interim rate","25.12","150","","","Percent of Total Billed Charges","neg_dollar:$38.84;150% of Medicaid interim rate","20.10","80","","","Percent of Total Billed Charges","neg_dollar:$20.10;Percent of Total Billed Charges","23.11","92","","","Percent of Total Billed Charges","neg_dollar:$23.11","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.12","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","25.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR","J2543","HCPCS","00409-3390-11","NDC","250","RC","","Facility","Outpatient","1","EA","28.85","28.85","","","","28.85","Fee Schedule","","","","","28.85","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","28.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.00","52","","","Percent of Total Billed Charges","neg_dollar:$15;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.00","52","","","Percent of Total Billed Charges","neg_dollar:$15;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.81","86","","","Percent of Total Billed Charges","neg_dollar:$24.81","20.19","70","","","Percent of Total Billed Charges","neg_dollar:$20.19","","52","","28.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","16.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.94;102% of Medicaid interim rate","21.63","75","","","Percent of Total Billed Charges","neg_dollar:$21.63","24.81","86","","","Percent of Total Billed Charges","neg_dollar:$24.81","20.19","70","","","Percent of Total Billed Charges","neg_dollar:$20.19","16.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.44;103.5% of Medicaid interim rate","28.85","150","","","Percent of Total Billed Charges","neg_dollar:$44.60;150% of Medicaid interim rate","23.08","80","","","Percent of Total Billed Charges","neg_dollar:$23.08;Percent of Total Billed Charges","26.54","92","","","Percent of Total Billed Charges","neg_dollar:$26.54","15.00","52","","","Percent of Total Billed Charges","neg_dollar:$15;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","28.85","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","28.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR","J2543","HCPCS","60505-6159-0","NDC","250","RC","","Facility","Outpatient","1","EA","25.12","25.12","","","","25.12","Fee Schedule","","","","","25.12","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","25.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","","52","","25.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.76;102% of Medicaid interim rate","18.84","75","","","Percent of Total Billed Charges","neg_dollar:$18.84","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","14.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.32;103.5% of Medicaid interim rate","25.12","150","","","Percent of Total Billed Charges","neg_dollar:$38.84;150% of Medicaid interim rate","20.10","80","","","Percent of Total Billed Charges","neg_dollar:$20.10;Percent of Total Billed Charges","23.11","92","","","Percent of Total Billed Charges","neg_dollar:$23.11","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.12","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","25.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR","J2543","HCPCS","64679-012-01","NDC","250","RC","","Facility","Outpatient","1","EA","25.12","25.12","","","","25.12","Fee Schedule","","","","","25.12","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","25.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","","52","","25.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.76;102% of Medicaid interim rate","18.84","75","","","Percent of Total Billed Charges","neg_dollar:$18.84","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","14.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.32;103.5% of Medicaid interim rate","25.12","150","","","Percent of Total Billed Charges","neg_dollar:$38.84;150% of Medicaid interim rate","20.10","80","","","Percent of Total Billed Charges","neg_dollar:$20.10;Percent of Total Billed Charges","23.11","92","","","Percent of Total Billed Charges","neg_dollar:$23.11","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.12","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","25.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR","J2543","HCPCS","64679-012-02","NDC","636","RC","","Facility","Outpatient","1","EA","25.12","25.12","","","","25.12","Fee Schedule","","","","","25.12","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.76;102% of Medicaid interim rate","18.84","75","","","Percent of Total Billed Charges","neg_dollar:$18.84","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","14.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.32;103.5% of Medicaid interim rate","25.12","150","","","Percent of Total Billed Charges","neg_dollar:$38.84;150% of Medicaid interim rate","20.10","80","","","Percent of Total Billed Charges","neg_dollar:$20.10;Percent of Total Billed Charges","23.11","92","","","Percent of Total Billed Charges","neg_dollar:$23.11","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","25.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR","J2543","HCPCS","00409-3390-11","NDC","636","RC","","Facility","Outpatient","1","EA","28.85","28.85","","","","28.85","Fee Schedule","","","","","28.85","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","15.00","52","","","Percent of Total Billed Charges","neg_dollar:$15;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","28.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","28.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","24.81","86","","","Percent of Total Billed Charges","neg_dollar:$24.81","20.19","70","","","Percent of Total Billed Charges","neg_dollar:$20.19","15.00","52","","","Percent of Total Billed Charges","neg_dollar:$15;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.94;102% of Medicaid interim rate","21.63","75","","","Percent of Total Billed Charges","neg_dollar:$21.63","24.81","86","","","Percent of Total Billed Charges","neg_dollar:$24.81","20.19","70","","","Percent of Total Billed Charges","neg_dollar:$20.19","16.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.44;103.5% of Medicaid interim rate","28.85","150","","","Percent of Total Billed Charges","neg_dollar:$44.60;150% of Medicaid interim rate","23.08","80","","","Percent of Total Billed Charges","neg_dollar:$23.08;Percent of Total Billed Charges","26.54","92","","","Percent of Total Billed Charges","neg_dollar:$26.54","15.00","52","","","Percent of Total Billed Charges","neg_dollar:$15;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.00","52","","","Percent of Total Billed Charges","neg_dollar:$15;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","28.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR","J2543","HCPCS","60505-6159-0","NDC","636","RC","","Facility","Outpatient","1","EA","25.12","25.12","","","","25.12","Fee Schedule","","","","","25.12","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.76;102% of Medicaid interim rate","18.84","75","","","Percent of Total Billed Charges","neg_dollar:$18.84","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","14.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.32;103.5% of Medicaid interim rate","25.12","150","","","Percent of Total Billed Charges","neg_dollar:$38.84;150% of Medicaid interim rate","20.10","80","","","Percent of Total Billed Charges","neg_dollar:$20.10;Percent of Total Billed Charges","23.11","92","","","Percent of Total Billed Charges","neg_dollar:$23.11","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","25.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR","J2543","HCPCS","64679-012-02","NDC","250","RC","","Facility","Outpatient","1","EA","25.12","25.12","","","","25.12","Fee Schedule","","","","","25.12","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","25.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","","52","","25.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.76;102% of Medicaid interim rate","18.84","75","","","Percent of Total Billed Charges","neg_dollar:$18.84","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","14.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.32;103.5% of Medicaid interim rate","25.12","150","","","Percent of Total Billed Charges","neg_dollar:$38.84;150% of Medicaid interim rate","20.10","80","","","Percent of Total Billed Charges","neg_dollar:$20.10;Percent of Total Billed Charges","23.11","92","","","Percent of Total Billed Charges","neg_dollar:$23.11","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.12","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","25.00",""
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR","J2543","HCPCS","64679-012-01","NDC","636","RC","","Facility","Outpatient","1","EA","25.12","25.12","","","","25.12","Fee Schedule","","","","","25.12","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","25.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.76;102% of Medicaid interim rate","18.84","75","","","Percent of Total Billed Charges","neg_dollar:$18.84","21.60","86","","","Percent of Total Billed Charges","neg_dollar:$21.60","17.58","70","","","Percent of Total Billed Charges","neg_dollar:$17.58","14.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.32;103.5% of Medicaid interim rate","25.12","150","","","Percent of Total Billed Charges","neg_dollar:$38.84;150% of Medicaid interim rate","20.10","80","","","Percent of Total Billed Charges","neg_dollar:$20.10;Percent of Total Billed Charges","23.11","92","","","Percent of Total Billed Charges","neg_dollar:$23.11","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.06","52","","","Percent of Total Billed Charges","neg_dollar:$13.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","25.00",""
"PENTAMIDINE ISETHIONATE 300 MG IN SOLR","J2545","HCPCS","63323-877-15","NDC","250","RC","","Facility","Outpatient","1","UN","201.30","201.30","","","","201.30","Fee Schedule","","","","","201.30","Fee Schedule","","","","","201.30","Fee Schedule","","","52","","201.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","104.67","52","","","Percent of Total Billed Charges","neg_dollar:$104.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.67","52","","","Percent of Total Billed Charges","neg_dollar:$104.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","173.11","86","","","Percent of Total Billed Charges","neg_dollar:$173.11","140.91","70","","","Percent of Total Billed Charges","neg_dollar:$140.91","","52","","201.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","118.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$118.26;102% of Medicaid interim rate","150.97","75","","","Percent of Total Billed Charges","neg_dollar:$150.97","173.11","86","","","Percent of Total Billed Charges","neg_dollar:$173.11","140.91","70","","","Percent of Total Billed Charges","neg_dollar:$140.91","114.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$114.74;103.5% of Medicaid interim rate","201.30","150","","","Percent of Total Billed Charges","neg_dollar:$311.21;150% of Medicaid interim rate","161.04","80","","","Percent of Total Billed Charges","neg_dollar:$161.04;Percent of Total Billed Charges","185.19","92","","","Percent of Total Billed Charges","neg_dollar:$185.19","104.67","52","","","Percent of Total Billed Charges","neg_dollar:$104.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","201.30","Fee Schedule","","104.00","201.00",""
"PROMETHAZINE HCL 25 MG/ML IM/IV SOLN","J2550","HCPCS","00641-0928-21","NDC","636","RC","","Facility","Outpatient","1","UN","90.83","90.83","","","","33.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","47.23","52","","","Percent of Total Billed Charges","neg_dollar:$47.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.11","86","","","Percent of Total Billed Charges","neg_dollar:$78.11","63.58","70","","","Percent of Total Billed Charges","neg_dollar:$63.58","47.23","52","","","Percent of Total Billed Charges","neg_dollar:$47.23;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.36;102% of Medicaid interim rate","68.12","75","","","Percent of Total Billed Charges","neg_dollar:$68.12","78.11","86","","","Percent of Total Billed Charges","neg_dollar:$78.11","63.58","70","","","Percent of Total Billed Charges","neg_dollar:$63.58","51.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.77;103.5% of Medicaid interim rate","90.83","150","","","Percent of Total Billed Charges","neg_dollar:$140.42;150% of Medicaid interim rate","72.66","80","","","Percent of Total Billed Charges","neg_dollar:$72.66;Percent of Total Billed Charges","83.56","92","","","Percent of Total Billed Charges","neg_dollar:$83.56","47.23","52","","","Percent of Total Billed Charges","neg_dollar:$47.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.23","52","","","Percent of Total Billed Charges","neg_dollar:$47.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","90.00",""
"PROMETHAZINE HCL 25 MG/ML IM SOLN","J2550","HCPCS","00641-0928-21","NDC","636","RC","","Facility","Outpatient","1","UN","91.20","91.20","","","","33.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","47.42","52","","","Percent of Total Billed Charges","neg_dollar:$47.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.43","86","","","Percent of Total Billed Charges","neg_dollar:$78.43","63.83","70","","","Percent of Total Billed Charges","neg_dollar:$63.83","47.42","52","","","Percent of Total Billed Charges","neg_dollar:$47.42;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.57;102% of Medicaid interim rate","68.40","75","","","Percent of Total Billed Charges","neg_dollar:$68.40","78.43","86","","","Percent of Total Billed Charges","neg_dollar:$78.43","63.83","70","","","Percent of Total Billed Charges","neg_dollar:$63.83","51.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.98;103.5% of Medicaid interim rate","91.20","150","","","Percent of Total Billed Charges","neg_dollar:$140.99;150% of Medicaid interim rate","72.96","80","","","Percent of Total Billed Charges","neg_dollar:$72.96;Percent of Total Billed Charges","83.90","92","","","Percent of Total Billed Charges","neg_dollar:$83.90","47.42","52","","","Percent of Total Billed Charges","neg_dollar:$47.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.42","52","","","Percent of Total Billed Charges","neg_dollar:$47.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","91.00",""
"PROPOFOL 1000 MG/100ML IV EMUL","J2704","HCPCS","00069-0248-10","NDC","636","RC","","Facility","Outpatient","1","UN","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.12","86","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.91","70","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.98","75","","","Percent of Total Billed Charges","neg_dollar:$0.98","1.12","86","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.91","70","","","Percent of Total Billed Charges","neg_dollar:$0.91","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2.02;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.20","92","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PROPOFOL 1000 MG/100ML IV EMUL","J2704","HCPCS","43598-549-10","NDC","636","RC","","Facility","Outpatient","1","UN","1.43","1.43","","","","1.43","Fee Schedule","","","","","1.43","Fee Schedule","101% of Medicare Fee Schedule","","","","1.43","Fee Schedule","","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","86","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.00","70","","","Percent of Total Billed Charges","neg_dollar:$1","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.84;102% of Medicaid interim rate","1.07","75","","","Percent of Total Billed Charges","neg_dollar:$1.07","1.23","86","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.00","70","","","Percent of Total Billed Charges","neg_dollar:$1","0.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.81;103.5% of Medicaid interim rate","1.43","150","","","Percent of Total Billed Charges","neg_dollar:$2.21;150% of Medicaid interim rate","1.14","80","","","Percent of Total Billed Charges","neg_dollar:$1.14;Percent of Total Billed Charges","1.32","92","","","Percent of Total Billed Charges","neg_dollar:$1.32","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.74","52","","","Percent of Total Billed Charges","neg_dollar:$0.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PROPOFOL 1000 MG/100ML IV EMUL","J2704","HCPCS","43598-549-10","NDC","636","RC","","Facility","Outpatient","1","UN","1.47","1.47","","","","1.47","Fee Schedule","","","","","1.47","Fee Schedule","101% of Medicare Fee Schedule","","","","1.47","Fee Schedule","","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.26","86","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.86;102% of Medicaid interim rate","1.10","75","","","Percent of Total Billed Charges","neg_dollar:$1.10","1.26","86","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.83;103.5% of Medicaid interim rate","1.47","150","","","Percent of Total Billed Charges","neg_dollar:$2.27;150% of Medicaid interim rate","1.17","80","","","Percent of Total Billed Charges","neg_dollar:$1.17;Percent of Total Billed Charges","1.35","92","","","Percent of Total Billed Charges","neg_dollar:$1.35","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PROPOFOL 1000 MG/100ML IV EMUL","J2704","HCPCS","43598-549-10","NDC","636","RC","","Facility","Outpatient","1","UN","0.28","0.28","","","","0.28","Fee Schedule","","","","","0.28","Fee Schedule","101% of Medicare Fee Schedule","","","","0.28","Fee Schedule","","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.24","86","","","Percent of Total Billed Charges","neg_dollar:$0.24","0.19","70","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.16;102% of Medicaid interim rate","0.21","75","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.24","86","","","Percent of Total Billed Charges","neg_dollar:$0.24","0.19","70","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.16;103.5% of Medicaid interim rate","0.28","150","","","Percent of Total Billed Charges","neg_dollar:$0.43;150% of Medicaid interim rate","0.22","80","","","Percent of Total Billed Charges","neg_dollar:$0.22;Percent of Total Billed Charges","0.25","92","","","Percent of Total Billed Charges","neg_dollar:$0.25","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PROPOFOL 200 MG/20ML IV EMUL","J2704","HCPCS","63323-269-29","NDC","250","RC","","Facility","Outpatient","1","UN","4.97","4.97","","","","4.97","Fee Schedule","","","","","4.97","Fee Schedule","","","","","4.97","Fee Schedule","","","52","","4.97","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.58","52","","","Percent of Total Billed Charges","neg_dollar:$2.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.58","52","","","Percent of Total Billed Charges","neg_dollar:$2.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.27","86","","","Percent of Total Billed Charges","neg_dollar:$4.27","3.48","70","","","Percent of Total Billed Charges","neg_dollar:$3.48","","52","","4.97","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.92;102% of Medicaid interim rate","3.73","75","","","Percent of Total Billed Charges","neg_dollar:$3.73","4.27","86","","","Percent of Total Billed Charges","neg_dollar:$4.27","3.48","70","","","Percent of Total Billed Charges","neg_dollar:$3.48","2.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.83;103.5% of Medicaid interim rate","4.97","150","","","Percent of Total Billed Charges","neg_dollar:$7.69;150% of Medicaid interim rate","3.98","80","","","Percent of Total Billed Charges","neg_dollar:$3.98;Percent of Total Billed Charges","4.57","92","","","Percent of Total Billed Charges","neg_dollar:$4.57","2.58","52","","","Percent of Total Billed Charges","neg_dollar:$2.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.97","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"PROPOFOL 200 MG/20ML IV EMUL","J2704","HCPCS","63323-269-29","NDC","636","RC","","Facility","Outpatient","1","UN","4.95","4.95","","","","4.95","Fee Schedule","","","","","4.95","Fee Schedule","101% of Medicare Fee Schedule","","","","4.95","Fee Schedule","","2.57","52","","","Percent of Total Billed Charges","neg_dollar:$2.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.25","86","","","Percent of Total Billed Charges","neg_dollar:$4.25","3.46","70","","","Percent of Total Billed Charges","neg_dollar:$3.46","2.57","52","","","Percent of Total Billed Charges","neg_dollar:$2.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.90;102% of Medicaid interim rate","3.71","75","","","Percent of Total Billed Charges","neg_dollar:$3.71","4.25","86","","","Percent of Total Billed Charges","neg_dollar:$4.25","3.46","70","","","Percent of Total Billed Charges","neg_dollar:$3.46","2.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.82;103.5% of Medicaid interim rate","4.95","150","","","Percent of Total Billed Charges","neg_dollar:$7.65;150% of Medicaid interim rate","3.96","80","","","Percent of Total Billed Charges","neg_dollar:$3.96;Percent of Total Billed Charges","4.55","92","","","Percent of Total Billed Charges","neg_dollar:$4.55","2.57","52","","","Percent of Total Billed Charges","neg_dollar:$2.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.57","52","","","Percent of Total Billed Charges","neg_dollar:$2.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"PROPOFOL 200 MG/20ML IV EMUL","J2704","HCPCS","63323-269-29","NDC","636","RC","","Facility","Outpatient","1","UN","1","1.00","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% of Medicaid interim rate","0.75","75","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.00","150","","","Percent of Total Billed Charges","neg_dollar:$1.55;150% of Medicaid interim rate","0.80","80","","","Percent of Total Billed Charges","neg_dollar:$0.80;Percent of Total Billed Charges","0.92","92","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PROPOFOL 200 MG/20ML IV EMUL","J2704","HCPCS","63323-269-29","NDC","636","RC","","Facility","Outpatient","1","UN","4.72","4.72","","","","4.72","Fee Schedule","","","","","4.72","Fee Schedule","101% of Medicare Fee Schedule","","","","4.72","Fee Schedule","","2.45","52","","","Percent of Total Billed Charges","neg_dollar:$2.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.06","86","","","Percent of Total Billed Charges","neg_dollar:$4.06","3.31","70","","","Percent of Total Billed Charges","neg_dollar:$3.31","2.45","52","","","Percent of Total Billed Charges","neg_dollar:$2.45;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.77;102% of Medicaid interim rate","3.54","75","","","Percent of Total Billed Charges","neg_dollar:$3.54","4.06","86","","","Percent of Total Billed Charges","neg_dollar:$4.06","3.31","70","","","Percent of Total Billed Charges","neg_dollar:$3.31","2.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.69;103.5% of Medicaid interim rate","4.72","150","","","Percent of Total Billed Charges","neg_dollar:$7.31;150% of Medicaid interim rate","3.78","80","","","Percent of Total Billed Charges","neg_dollar:$3.78;Percent of Total Billed Charges","4.35","92","","","Percent of Total Billed Charges","neg_dollar:$4.35","2.45","52","","","Percent of Total Billed Charges","neg_dollar:$2.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.45","52","","","Percent of Total Billed Charges","neg_dollar:$2.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"PROPOFOL 500 MG/50ML IV EMUL","J2704","HCPCS","63323-269-50","NDC","636","RC","","Facility","Outpatient","1","UN","0.56","0.56","","","","0.56","Fee Schedule","","","","","0.56","Fee Schedule","101% of Medicare Fee Schedule","","","","0.56","Fee Schedule","","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","86","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","70","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% of Medicaid interim rate","0.42","75","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.48","86","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","70","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;103.5% of Medicaid interim rate","0.56","150","","","Percent of Total Billed Charges","neg_dollar:$0.87;150% of Medicaid interim rate","0.45","80","","","Percent of Total Billed Charges","neg_dollar:$0.45;Percent of Total Billed Charges","0.52","92","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","52","","","Percent of Total Billed Charges","neg_dollar:$0.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PROPOFOL 500 MG/50ML IV EMUL","J2704","HCPCS","63323-269-50","NDC","636","RC","","Facility","Outpatient","1","UN","2.34","2.34","","","","2.34","Fee Schedule","","","","","2.34","Fee Schedule","101% of Medicare Fee Schedule","","","","2.34","Fee Schedule","","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.34","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.34","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.01","86","","","Percent of Total Billed Charges","neg_dollar:$2.01","1.64","70","","","Percent of Total Billed Charges","neg_dollar:$1.64","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.37;102% of Medicaid interim rate","1.76","75","","","Percent of Total Billed Charges","neg_dollar:$1.76","2.01","86","","","Percent of Total Billed Charges","neg_dollar:$2.01","1.64","70","","","Percent of Total Billed Charges","neg_dollar:$1.64","1.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.33;103.5% of Medicaid interim rate","2.34","150","","","Percent of Total Billed Charges","neg_dollar:$3.63;150% of Medicaid interim rate","1.87","80","","","Percent of Total Billed Charges","neg_dollar:$1.87;Percent of Total Billed Charges","2.16","92","","","Percent of Total Billed Charges","neg_dollar:$2.16","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"PROPOFOL 500 MG/50ML IV EMUL","J2704","HCPCS","63323-269-50","NDC","636","RC","","Facility","Outpatient","1","UN","2.39","2.39","","","","2.39","Fee Schedule","","","","","2.39","Fee Schedule","101% of Medicare Fee Schedule","","","","2.39","Fee Schedule","","1.24","52","","","Percent of Total Billed Charges","neg_dollar:$1.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.39","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.39","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.05","86","","","Percent of Total Billed Charges","neg_dollar:$2.05","1.67","70","","","Percent of Total Billed Charges","neg_dollar:$1.67","1.24","52","","","Percent of Total Billed Charges","neg_dollar:$1.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.40;102% of Medicaid interim rate","1.79","75","","","Percent of Total Billed Charges","neg_dollar:$1.79","2.05","86","","","Percent of Total Billed Charges","neg_dollar:$2.05","1.67","70","","","Percent of Total Billed Charges","neg_dollar:$1.67","1.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.36;103.5% of Medicaid interim rate","2.39","150","","","Percent of Total Billed Charges","neg_dollar:$3.70;150% of Medicaid interim rate","1.91","80","","","Percent of Total Billed Charges","neg_dollar:$1.91;Percent of Total Billed Charges","2.20","92","","","Percent of Total Billed Charges","neg_dollar:$2.20","1.24","52","","","Percent of Total Billed Charges","neg_dollar:$1.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","52","","","Percent of Total Billed Charges","neg_dollar:$1.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"PROPOFOL 500 MG/50ML IV EMUL","J2704","HCPCS","63323-269-50","NDC","250","RC","","Facility","Outpatient","1","UN","2.35","2.35","","","","2.35","Fee Schedule","","","","","2.35","Fee Schedule","","","","","2.35","Fee Schedule","","","52","","2.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.02","86","","","Percent of Total Billed Charges","neg_dollar:$2.02","1.64","70","","","Percent of Total Billed Charges","neg_dollar:$1.64","","52","","2.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.38;102% of Medicaid interim rate","1.76","75","","","Percent of Total Billed Charges","neg_dollar:$1.76","2.02","86","","","Percent of Total Billed Charges","neg_dollar:$2.02","1.64","70","","","Percent of Total Billed Charges","neg_dollar:$1.64","1.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.33;103.5% of Medicaid interim rate","2.35","150","","","Percent of Total Billed Charges","neg_dollar:$3.63;150% of Medicaid interim rate","1.88","80","","","Percent of Total Billed Charges","neg_dollar:$1.88;Percent of Total Billed Charges","2.16","92","","","Percent of Total Billed Charges","neg_dollar:$2.16","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.35","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","J2765","HCPCS","00409-3414-18","NDC","636","RC","","Facility","Outpatient","1","ML","89.88","89.88","","","","1.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.74","52","","","Percent of Total Billed Charges","neg_dollar:$46.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","77.30","86","","","Percent of Total Billed Charges","neg_dollar:$77.30","62.92","70","","","Percent of Total Billed Charges","neg_dollar:$62.92","46.74","52","","","Percent of Total Billed Charges","neg_dollar:$46.74;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.80;102% of Medicaid interim rate","67.41","75","","","Percent of Total Billed Charges","neg_dollar:$67.41","77.30","86","","","Percent of Total Billed Charges","neg_dollar:$77.30","62.92","70","","","Percent of Total Billed Charges","neg_dollar:$62.92","51.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.23;103.5% of Medicaid interim rate","89.88","150","","","Percent of Total Billed Charges","neg_dollar:$138.96;150% of Medicaid interim rate","71.90","80","","","Percent of Total Billed Charges","neg_dollar:$71.90;Percent of Total Billed Charges","82.69","92","","","Percent of Total Billed Charges","neg_dollar:$82.69","46.74","52","","","Percent of Total Billed Charges","neg_dollar:$46.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.74","52","","","Percent of Total Billed Charges","neg_dollar:$46.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","89.00",""
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","J2765","HCPCS","00409-3414-01","NDC","636","RC","","Facility","Outpatient","1","ML","90","90.00","","","","1.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.87;102% of Medicaid interim rate","67.50","75","","","Percent of Total Billed Charges","neg_dollar:$67.50","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","51.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.30;103.5% of Medicaid interim rate","90.00","150","","","Percent of Total Billed Charges","neg_dollar:$139.14;150% of Medicaid interim rate","72.00","80","","","Percent of Total Billed Charges","neg_dollar:$72;Percent of Total Billed Charges","82.80","92","","","Percent of Total Billed Charges","neg_dollar:$82.80","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","90.00",""
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","J2765","HCPCS","00409-3414-21","NDC","636","RC","","Facility","Outpatient","1","ML","89.68","89.68","","","","1.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.63","52","","","Percent of Total Billed Charges","neg_dollar:$46.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","77.13","86","","","Percent of Total Billed Charges","neg_dollar:$77.13","62.78","70","","","Percent of Total Billed Charges","neg_dollar:$62.78","46.63","52","","","Percent of Total Billed Charges","neg_dollar:$46.63;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.69;102% of Medicaid interim rate","67.26","75","","","Percent of Total Billed Charges","neg_dollar:$67.26","77.13","86","","","Percent of Total Billed Charges","neg_dollar:$77.13","62.78","70","","","Percent of Total Billed Charges","neg_dollar:$62.78","51.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.12;103.5% of Medicaid interim rate","89.68","150","","","Percent of Total Billed Charges","neg_dollar:$138.66;150% of Medicaid interim rate","71.75","80","","","Percent of Total Billed Charges","neg_dollar:$71.75;Percent of Total Billed Charges","82.51","92","","","Percent of Total Billed Charges","neg_dollar:$82.51","46.63","52","","","Percent of Total Billed Charges","neg_dollar:$46.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.63","52","","","Percent of Total Billed Charges","neg_dollar:$46.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","89.00",""
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","J2765","HCPCS","00409-3414-18","NDC","636","RC","","Facility","Outpatient","1","ML","90","90.00","","","","1.00","Fee Schedule","","","","","46.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.87;102% of Medicaid interim rate","67.50","75","","","Percent of Total Billed Charges","neg_dollar:$67.50","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","51.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.30;103.5% of Medicaid interim rate","90.00","150","","","Percent of Total Billed Charges","neg_dollar:$139.14;150% of Medicaid interim rate","72.00","80","","","Percent of Total Billed Charges","neg_dollar:$72;Percent of Total Billed Charges","82.80","92","","","Percent of Total Billed Charges","neg_dollar:$82.80","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","90.00",""
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","J2765","HCPCS","00409-3414-18","NDC","250","RC","","Facility","Outpatient","1","ML","90","90.00","","","","1.00","Fee Schedule","","","","","46.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","90.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.87;102% of Medicaid interim rate","67.50","75","","","Percent of Total Billed Charges","neg_dollar:$67.50","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","51.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.30;103.5% of Medicaid interim rate","90.00","150","","","Percent of Total Billed Charges","neg_dollar:$139.14;150% of Medicaid interim rate","72.00","80","","","Percent of Total Billed Charges","neg_dollar:$72;Percent of Total Billed Charges","82.80","92","","","Percent of Total Billed Charges","neg_dollar:$82.80","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","90.00",""
"METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN","J2765","HCPCS","00409-3414-21","NDC","250","RC","","Facility","Outpatient","1","ML","90","90.00","","","","1.00","Fee Schedule","","","","","46.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","90.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.87;102% of Medicaid interim rate","67.50","75","","","Percent of Total Billed Charges","neg_dollar:$67.50","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","51.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.30;103.5% of Medicaid interim rate","90.00","150","","","Percent of Total Billed Charges","neg_dollar:$139.14;150% of Medicaid interim rate","72.00","80","","","Percent of Total Billed Charges","neg_dollar:$72;Percent of Total Billed Charges","82.80","92","","","Percent of Total Billed Charges","neg_dollar:$82.80","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","90.00",""
"REGADENOSON 0.4 MG/5ML IV SOLN","J2785","HCPCS","71288-201-85","NDC","636","RC","","Facility","Outpatient","1","UN","31.87","31.87","","","","31.87","Fee Schedule","","","","","31.87","Fee Schedule","101% of Medicare Fee Schedule","","","","31.87","Fee Schedule","","16.57","52","","","Percent of Total Billed Charges","neg_dollar:$16.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","31.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","27.41","86","","","Percent of Total Billed Charges","neg_dollar:$27.41","22.31","70","","","Percent of Total Billed Charges","neg_dollar:$22.31","16.57","52","","","Percent of Total Billed Charges","neg_dollar:$16.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","18.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.72;102% of Medicaid interim rate","23.90","75","","","Percent of Total Billed Charges","neg_dollar:$23.90","27.41","86","","","Percent of Total Billed Charges","neg_dollar:$27.41","22.31","70","","","Percent of Total Billed Charges","neg_dollar:$22.31","18.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.16;103.5% of Medicaid interim rate","31.87","150","","","Percent of Total Billed Charges","neg_dollar:$49.28;150% of Medicaid interim rate","25.50","80","","","Percent of Total Billed Charges","neg_dollar:$25.50;Percent of Total Billed Charges","29.32","92","","","Percent of Total Billed Charges","neg_dollar:$29.32","16.57","52","","","Percent of Total Billed Charges","neg_dollar:$16.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.57","52","","","Percent of Total Billed Charges","neg_dollar:$16.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","31.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-25","NDC","250","RC","","Facility","Outpatient","1","UN","4.37","4.37","","","","4.37","Fee Schedule","","","","","4.37","Fee Schedule","","","","","4.37","Fee Schedule","","","52","","4.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.75","86","","","Percent of Total Billed Charges","neg_dollar:$3.75","3.06","70","","","Percent of Total Billed Charges","neg_dollar:$3.06","","52","","4.37","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.56;102% of Medicaid interim rate","3.27","75","","","Percent of Total Billed Charges","neg_dollar:$3.27","3.75","86","","","Percent of Total Billed Charges","neg_dollar:$3.75","3.06","70","","","Percent of Total Billed Charges","neg_dollar:$3.06","2.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.49;103.5% of Medicaid interim rate","4.37","150","","","Percent of Total Billed Charges","neg_dollar:$6.75;150% of Medicaid interim rate","3.49","80","","","Percent of Total Billed Charges","neg_dollar:$3.49;Percent of Total Billed Charges","4.02","92","","","Percent of Total Billed Charges","neg_dollar:$4.02","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.37","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-25","NDC","636","RC","","Facility","Outpatient","1","UN","4.96","4.96","","","","4.96","Fee Schedule","","","","","4.96","Fee Schedule","101% of Medicare Fee Schedule","","","","4.96","Fee Schedule","","2.57","52","","","Percent of Total Billed Charges","neg_dollar:$2.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.26","86","","","Percent of Total Billed Charges","neg_dollar:$4.26","3.47","70","","","Percent of Total Billed Charges","neg_dollar:$3.47","2.57","52","","","Percent of Total Billed Charges","neg_dollar:$2.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.91;102% of Medicaid interim rate","3.72","75","","","Percent of Total Billed Charges","neg_dollar:$3.72","4.26","86","","","Percent of Total Billed Charges","neg_dollar:$4.26","3.47","70","","","Percent of Total Billed Charges","neg_dollar:$3.47","2.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.82;103.5% of Medicaid interim rate","4.96","150","","","Percent of Total Billed Charges","neg_dollar:$7.66;150% of Medicaid interim rate","3.96","80","","","Percent of Total Billed Charges","neg_dollar:$3.96;Percent of Total Billed Charges","4.56","92","","","Percent of Total Billed Charges","neg_dollar:$4.56","2.57","52","","","Percent of Total Billed Charges","neg_dollar:$2.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.57","52","","","Percent of Total Billed Charges","neg_dollar:$2.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-25","NDC","636","RC","","Facility","Outpatient","1","UN","4.37","4.37","","","","4.37","Fee Schedule","","","","","4.37","Fee Schedule","101% of Medicare Fee Schedule","","","","4.37","Fee Schedule","","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.75","86","","","Percent of Total Billed Charges","neg_dollar:$3.75","3.06","70","","","Percent of Total Billed Charges","neg_dollar:$3.06","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.56;102% of Medicaid interim rate","3.27","75","","","Percent of Total Billed Charges","neg_dollar:$3.27","3.75","86","","","Percent of Total Billed Charges","neg_dollar:$3.75","3.06","70","","","Percent of Total Billed Charges","neg_dollar:$3.06","2.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.49;103.5% of Medicaid interim rate","4.37","150","","","Percent of Total Billed Charges","neg_dollar:$6.75;150% of Medicaid interim rate","3.49","80","","","Percent of Total Billed Charges","neg_dollar:$3.49;Percent of Total Billed Charges","4.02","92","","","Percent of Total Billed Charges","neg_dollar:$4.02","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-25","NDC","636","RC","","Facility","Outpatient","1","UN","2.68","2.68","","","","2.68","Fee Schedule","","","","","2.68","Fee Schedule","101% of Medicare Fee Schedule","","","","2.68","Fee Schedule","","1.39","52","","","Percent of Total Billed Charges","neg_dollar:$1.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.68","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.31","86","","","Percent of Total Billed Charges","neg_dollar:$2.31","1.88","70","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.39","52","","","Percent of Total Billed Charges","neg_dollar:$1.39;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.57;102% of Medicaid interim rate","2.01","75","","","Percent of Total Billed Charges","neg_dollar:$2.01","2.31","86","","","Percent of Total Billed Charges","neg_dollar:$2.31","1.88","70","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.53;103.5% of Medicaid interim rate","2.68","150","","","Percent of Total Billed Charges","neg_dollar:$4.15;150% of Medicaid interim rate","2.14","80","","","Percent of Total Billed Charges","neg_dollar:$2.14;Percent of Total Billed Charges","2.47","92","","","Percent of Total Billed Charges","neg_dollar:$2.47","1.39","52","","","Percent of Total Billed Charges","neg_dollar:$1.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.39","52","","","Percent of Total Billed Charges","neg_dollar:$1.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-22","NDC","636","RC","","Facility","Outpatient","1","UN","5.85","5.85","","","","5.85","Fee Schedule","","","","","5.85","Fee Schedule","101% of Medicare Fee Schedule","","","","5.85","Fee Schedule","","3.04","52","","","Percent of Total Billed Charges","neg_dollar:$3.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.03","86","","","Percent of Total Billed Charges","neg_dollar:$5.03","4.09","70","","","Percent of Total Billed Charges","neg_dollar:$4.09","3.04","52","","","Percent of Total Billed Charges","neg_dollar:$3.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","3.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.43;102% of Medicaid interim rate","4.38","75","","","Percent of Total Billed Charges","neg_dollar:$4.38","5.03","86","","","Percent of Total Billed Charges","neg_dollar:$5.03","4.09","70","","","Percent of Total Billed Charges","neg_dollar:$4.09","3.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.33;103.5% of Medicaid interim rate","5.85","150","","","Percent of Total Billed Charges","neg_dollar:$9.04;150% of Medicaid interim rate","4.68","80","","","Percent of Total Billed Charges","neg_dollar:$4.68;Percent of Total Billed Charges","5.38","92","","","Percent of Total Billed Charges","neg_dollar:$5.38","3.04","52","","","Percent of Total Billed Charges","neg_dollar:$3.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.04","52","","","Percent of Total Billed Charges","neg_dollar:$3.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","5.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-22","NDC","250","RC","","Facility","Outpatient","1","UN","4.09","4.09","","","","4.09","Fee Schedule","","","","","4.09","Fee Schedule","","","","","4.09","Fee Schedule","","","52","","4.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.13","52","","","Percent of Total Billed Charges","neg_dollar:$2.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.13","52","","","Percent of Total Billed Charges","neg_dollar:$2.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.52","86","","","Percent of Total Billed Charges","neg_dollar:$3.52","2.86","70","","","Percent of Total Billed Charges","neg_dollar:$2.86","","52","","4.09","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.40;102% of Medicaid interim rate","3.07","75","","","Percent of Total Billed Charges","neg_dollar:$3.07","3.52","86","","","Percent of Total Billed Charges","neg_dollar:$3.52","2.86","70","","","Percent of Total Billed Charges","neg_dollar:$2.86","2.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.33;103.5% of Medicaid interim rate","4.09","150","","","Percent of Total Billed Charges","neg_dollar:$6.33;150% of Medicaid interim rate","3.27","80","","","Percent of Total Billed Charges","neg_dollar:$3.27;Percent of Total Billed Charges","3.77","92","","","Percent of Total Billed Charges","neg_dollar:$3.77","2.13","52","","","Percent of Total Billed Charges","neg_dollar:$2.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.09","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-22","NDC","636","RC","","Facility","Outpatient","1","UN","4.37","4.37","","","","4.37","Fee Schedule","","","","","4.37","Fee Schedule","101% of Medicare Fee Schedule","","","","4.37","Fee Schedule","","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.76","86","","","Percent of Total Billed Charges","neg_dollar:$3.76","3.06","70","","","Percent of Total Billed Charges","neg_dollar:$3.06","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.57;102% of Medicaid interim rate","3.28","75","","","Percent of Total Billed Charges","neg_dollar:$3.28","3.76","86","","","Percent of Total Billed Charges","neg_dollar:$3.76","3.06","70","","","Percent of Total Billed Charges","neg_dollar:$3.06","2.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.49;103.5% of Medicaid interim rate","4.37","150","","","Percent of Total Billed Charges","neg_dollar:$6.76;150% of Medicaid interim rate","3.50","80","","","Percent of Total Billed Charges","neg_dollar:$3.50;Percent of Total Billed Charges","4.02","92","","","Percent of Total Billed Charges","neg_dollar:$4.02","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-25","NDC","636","RC","","Facility","Outpatient","1","UN","8.16","8.16","","","","8.16","Fee Schedule","","","","","8.16","Fee Schedule","101% of Medicare Fee Schedule","","","","7.00","Fee Schedule","","4.24","52","","","Percent of Total Billed Charges","neg_dollar:$4.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.01","86","","","Percent of Total Billed Charges","neg_dollar:$7.01","5.71","70","","","Percent of Total Billed Charges","neg_dollar:$5.71","4.24","52","","","Percent of Total Billed Charges","neg_dollar:$4.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","4.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.79;102% of Medicaid interim rate","6.12","75","","","Percent of Total Billed Charges","neg_dollar:$6.12","7.01","86","","","Percent of Total Billed Charges","neg_dollar:$7.01","5.71","70","","","Percent of Total Billed Charges","neg_dollar:$5.71","4.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.65;103.5% of Medicaid interim rate","8.16","150","","","Percent of Total Billed Charges","neg_dollar:$12.61;150% of Medicaid interim rate","6.53","80","","","Percent of Total Billed Charges","neg_dollar:$6.53;Percent of Total Billed Charges","7.50","92","","","Percent of Total Billed Charges","neg_dollar:$7.50","4.24","52","","","Percent of Total Billed Charges","neg_dollar:$4.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.24","52","","","Percent of Total Billed Charges","neg_dollar:$4.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","8.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-22","NDC","250","RC","","Facility","Outpatient","1","UN","5.72","5.72","","","","5.72","Fee Schedule","","","","","5.72","Fee Schedule","","","","","5.72","Fee Schedule","","","52","","5.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.97","52","","","Percent of Total Billed Charges","neg_dollar:$2.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.97","52","","","Percent of Total Billed Charges","neg_dollar:$2.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.92","86","","","Percent of Total Billed Charges","neg_dollar:$4.92","4.00","70","","","Percent of Total Billed Charges","neg_dollar:$4","","52","","5.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.36;102% of Medicaid interim rate","4.29","75","","","Percent of Total Billed Charges","neg_dollar:$4.29","4.92","86","","","Percent of Total Billed Charges","neg_dollar:$4.92","4.00","70","","","Percent of Total Billed Charges","neg_dollar:$4","3.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.26;103.5% of Medicaid interim rate","5.72","150","","","Percent of Total Billed Charges","neg_dollar:$8.84;150% of Medicaid interim rate","4.57","80","","","Percent of Total Billed Charges","neg_dollar:$4.57;Percent of Total Billed Charges","5.26","92","","","Percent of Total Billed Charges","neg_dollar:$5.26","2.97","52","","","Percent of Total Billed Charges","neg_dollar:$2.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.72","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-22","NDC","250","RC","","Facility","Outpatient","1","UN","4.37","4.37","","","","4.37","Fee Schedule","","","","","4.37","Fee Schedule","","","","","4.37","Fee Schedule","","","52","","4.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.75","86","","","Percent of Total Billed Charges","neg_dollar:$3.75","3.06","70","","","Percent of Total Billed Charges","neg_dollar:$3.06","","52","","4.37","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.56;102% of Medicaid interim rate","3.27","75","","","Percent of Total Billed Charges","neg_dollar:$3.27","3.75","86","","","Percent of Total Billed Charges","neg_dollar:$3.75","3.06","70","","","Percent of Total Billed Charges","neg_dollar:$3.06","2.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.49;103.5% of Medicaid interim rate","4.37","150","","","Percent of Total Billed Charges","neg_dollar:$6.75;150% of Medicaid interim rate","3.49","80","","","Percent of Total Billed Charges","neg_dollar:$3.49;Percent of Total Billed Charges","4.02","92","","","Percent of Total Billed Charges","neg_dollar:$4.02","2.27","52","","","Percent of Total Billed Charges","neg_dollar:$2.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.37","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-22","NDC","636","RC","","Facility","Outpatient","1","UN","5.06","5.06","","","","5.06","Fee Schedule","","","","","5.06","Fee Schedule","101% of Medicare Fee Schedule","","","","5.06","Fee Schedule","","2.63","52","","","Percent of Total Billed Charges","neg_dollar:$2.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.35","86","","","Percent of Total Billed Charges","neg_dollar:$4.35","3.54","70","","","Percent of Total Billed Charges","neg_dollar:$3.54","2.63","52","","","Percent of Total Billed Charges","neg_dollar:$2.63;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.97;102% of Medicaid interim rate","3.79","75","","","Percent of Total Billed Charges","neg_dollar:$3.79","4.35","86","","","Percent of Total Billed Charges","neg_dollar:$4.35","3.54","70","","","Percent of Total Billed Charges","neg_dollar:$3.54","2.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.88;103.5% of Medicaid interim rate","5.06","150","","","Percent of Total Billed Charges","neg_dollar:$7.82;150% of Medicaid interim rate","4.04","80","","","Percent of Total Billed Charges","neg_dollar:$4.04;Percent of Total Billed Charges","4.65","92","","","Percent of Total Billed Charges","neg_dollar:$4.65","2.63","52","","","Percent of Total Billed Charges","neg_dollar:$2.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.63","52","","","Percent of Total Billed Charges","neg_dollar:$2.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","5.00",""
"METHYLPREDNISOLONE NA SUC (PF) 125 MG IJ SOLR","J2919","HCPCS","00009-0047-22","NDC","636","RC","","Facility","Outpatient","1","UN","2.65","2.65","","","","2.65","Fee Schedule","","","","","2.65","Fee Schedule","101% of Medicare Fee Schedule","","","","2.65","Fee Schedule","","1.38","52","","","Percent of Total Billed Charges","neg_dollar:$1.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.28","86","","","Percent of Total Billed Charges","neg_dollar:$2.28","1.85","70","","","Percent of Total Billed Charges","neg_dollar:$1.85","1.38","52","","","Percent of Total Billed Charges","neg_dollar:$1.38;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.55;102% of Medicaid interim rate","1.99","75","","","Percent of Total Billed Charges","neg_dollar:$1.99","2.28","86","","","Percent of Total Billed Charges","neg_dollar:$2.28","1.85","70","","","Percent of Total Billed Charges","neg_dollar:$1.85","1.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.51;103.5% of Medicaid interim rate","2.65","150","","","Percent of Total Billed Charges","neg_dollar:$4.10;150% of Medicaid interim rate","2.12","80","","","Percent of Total Billed Charges","neg_dollar:$2.12;Percent of Total Billed Charges","2.44","92","","","Percent of Total Billed Charges","neg_dollar:$2.44","1.38","52","","","Percent of Total Billed Charges","neg_dollar:$1.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.38","52","","","Percent of Total Billed Charges","neg_dollar:$1.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","J2919","HCPCS","00009-0039-28","NDC","250","RC","","Facility","Outpatient","1","UN","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","","52","","0.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% of Medicaid interim rate","0.63","75","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.31;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.85","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","J2919","HCPCS","00009-0039-30","NDC","636","RC","","Facility","Outpatient","1","UN","12.63","12.63","","","","12.63","Fee Schedule","","","","","12.63","Fee Schedule","101% of Medicare Fee Schedule","","","","7.00","Fee Schedule","","6.56","52","","","Percent of Total Billed Charges","neg_dollar:$6.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.86","86","","","Percent of Total Billed Charges","neg_dollar:$10.86","8.84","70","","","Percent of Total Billed Charges","neg_dollar:$8.84","6.56","52","","","Percent of Total Billed Charges","neg_dollar:$6.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.42;102% of Medicaid interim rate","9.47","75","","","Percent of Total Billed Charges","neg_dollar:$9.47","10.86","86","","","Percent of Total Billed Charges","neg_dollar:$10.86","8.84","70","","","Percent of Total Billed Charges","neg_dollar:$8.84","7.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.19;103.5% of Medicaid interim rate","12.63","150","","","Percent of Total Billed Charges","neg_dollar:$19.52;150% of Medicaid interim rate","10.10","80","","","Percent of Total Billed Charges","neg_dollar:$10.10;Percent of Total Billed Charges","11.62","92","","","Percent of Total Billed Charges","neg_dollar:$11.62","6.56","52","","","Percent of Total Billed Charges","neg_dollar:$6.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.56","52","","","Percent of Total Billed Charges","neg_dollar:$6.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","12.00",""
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","J2919","HCPCS","00009-0039-30","NDC","250","RC","","Facility","Outpatient","1","UN","12.05","12.05","","","","12.05","Fee Schedule","","","","","12.05","Fee Schedule","","","","","7.00","Fee Schedule","","","52","","12.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.26","52","","","Percent of Total Billed Charges","neg_dollar:$6.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.26","52","","","Percent of Total Billed Charges","neg_dollar:$6.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.36","86","","","Percent of Total Billed Charges","neg_dollar:$10.36","8.43","70","","","Percent of Total Billed Charges","neg_dollar:$8.43","","52","","12.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.08;102% of Medicaid interim rate","9.04","75","","","Percent of Total Billed Charges","neg_dollar:$9.04","10.36","86","","","Percent of Total Billed Charges","neg_dollar:$10.36","8.43","70","","","Percent of Total Billed Charges","neg_dollar:$8.43","6.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.87;103.5% of Medicaid interim rate","12.05","150","","","Percent of Total Billed Charges","neg_dollar:$18.63;150% of Medicaid interim rate","9.64","80","","","Percent of Total Billed Charges","neg_dollar:$9.64;Percent of Total Billed Charges","11.09","92","","","Percent of Total Billed Charges","neg_dollar:$11.09","6.26","52","","","Percent of Total Billed Charges","neg_dollar:$6.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.05","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","12.00",""
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","J2919","HCPCS","00009-0039-28","NDC","636","RC","","Facility","Outpatient","1","UN","12.63","12.63","","","","12.63","Fee Schedule","","","","","12.63","Fee Schedule","101% of Medicare Fee Schedule","","","","7.00","Fee Schedule","","6.56","52","","","Percent of Total Billed Charges","neg_dollar:$6.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.86","86","","","Percent of Total Billed Charges","neg_dollar:$10.86","8.84","70","","","Percent of Total Billed Charges","neg_dollar:$8.84","6.56","52","","","Percent of Total Billed Charges","neg_dollar:$6.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.42;102% of Medicaid interim rate","9.47","75","","","Percent of Total Billed Charges","neg_dollar:$9.47","10.86","86","","","Percent of Total Billed Charges","neg_dollar:$10.86","8.84","70","","","Percent of Total Billed Charges","neg_dollar:$8.84","7.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.19;103.5% of Medicaid interim rate","12.63","150","","","Percent of Total Billed Charges","neg_dollar:$19.52;150% of Medicaid interim rate","10.10","80","","","Percent of Total Billed Charges","neg_dollar:$10.10;Percent of Total Billed Charges","11.62","92","","","Percent of Total Billed Charges","neg_dollar:$11.62","6.56","52","","","Percent of Total Billed Charges","neg_dollar:$6.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.56","52","","","Percent of Total Billed Charges","neg_dollar:$6.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","12.00",""
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","J2919","HCPCS","00009-0039-30","NDC","250","RC","","Facility","Outpatient","1","UN","8.52","8.52","","","","8.52","Fee Schedule","","","","","8.52","Fee Schedule","","","","","7.00","Fee Schedule","","","52","","8.52","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.43","52","","","Percent of Total Billed Charges","neg_dollar:$4.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.43","52","","","Percent of Total Billed Charges","neg_dollar:$4.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.33","86","","","Percent of Total Billed Charges","neg_dollar:$7.33","5.96","70","","","Percent of Total Billed Charges","neg_dollar:$5.96","","52","","8.52","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$5;102% of Medicaid interim rate","6.39","75","","","Percent of Total Billed Charges","neg_dollar:$6.39","7.33","86","","","Percent of Total Billed Charges","neg_dollar:$7.33","5.96","70","","","Percent of Total Billed Charges","neg_dollar:$5.96","4.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.86;103.5% of Medicaid interim rate","8.52","150","","","Percent of Total Billed Charges","neg_dollar:$13.18;150% of Medicaid interim rate","6.82","80","","","Percent of Total Billed Charges","neg_dollar:$6.82;Percent of Total Billed Charges","7.84","92","","","Percent of Total Billed Charges","neg_dollar:$7.84","4.43","52","","","Percent of Total Billed Charges","neg_dollar:$4.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","8.52","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","8.00",""
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","J2919","HCPCS","00009-0039-30","NDC","250","RC","","Facility","Outpatient","1","UN","16.27","16.27","","","","16.27","Fee Schedule","","","","","16.27","Fee Schedule","","","","","7.00","Fee Schedule","","","52","","16.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.46","52","","","Percent of Total Billed Charges","neg_dollar:$8.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.46","52","","","Percent of Total Billed Charges","neg_dollar:$8.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.99","86","","","Percent of Total Billed Charges","neg_dollar:$13.99","11.39","70","","","Percent of Total Billed Charges","neg_dollar:$11.39","","52","","16.27","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.56;102% of Medicaid interim rate","12.20","75","","","Percent of Total Billed Charges","neg_dollar:$12.20","13.99","86","","","Percent of Total Billed Charges","neg_dollar:$13.99","11.39","70","","","Percent of Total Billed Charges","neg_dollar:$11.39","9.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.27;103.5% of Medicaid interim rate","16.27","150","","","Percent of Total Billed Charges","neg_dollar:$25.16;150% of Medicaid interim rate","13.02","80","","","Percent of Total Billed Charges","neg_dollar:$13.02;Percent of Total Billed Charges","14.97","92","","","Percent of Total Billed Charges","neg_dollar:$14.97","8.46","52","","","Percent of Total Billed Charges","neg_dollar:$8.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","16.27","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","16.00",""
"METHYLPREDNISOLONE NA SUC (PF) 40 MG IJ SOLR","J2919","HCPCS","00009-0039-28","NDC","636","RC","","Facility","Outpatient","1","UN","10.27","10.27","","","","10.27","Fee Schedule","","","","","10.27","Fee Schedule","101% of Medicare Fee Schedule","","","","7.00","Fee Schedule","","5.34","52","","","Percent of Total Billed Charges","neg_dollar:$5.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.83","86","","","Percent of Total Billed Charges","neg_dollar:$8.83","7.19","70","","","Percent of Total Billed Charges","neg_dollar:$7.19","5.34","52","","","Percent of Total Billed Charges","neg_dollar:$5.34;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.03;102% of Medicaid interim rate","7.70","75","","","Percent of Total Billed Charges","neg_dollar:$7.70","8.83","86","","","Percent of Total Billed Charges","neg_dollar:$8.83","7.19","70","","","Percent of Total Billed Charges","neg_dollar:$7.19","5.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.85;103.5% of Medicaid interim rate","10.27","150","","","Percent of Total Billed Charges","neg_dollar:$15.88;150% of Medicaid interim rate","8.22","80","","","Percent of Total Billed Charges","neg_dollar:$8.22;Percent of Total Billed Charges","9.45","92","","","Percent of Total Billed Charges","neg_dollar:$9.45","5.34","52","","","Percent of Total Billed Charges","neg_dollar:$5.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.34","52","","","Percent of Total Billed Charges","neg_dollar:$5.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"ALTEPLASE 2 MG IJ SOLR","J2997","HCPCS","50242-041-64","NDC","250","RC","","Facility","Outpatient","1","UN","223.04","223.04","","","","150.00","Fee Schedule","","","","","208.00","Fee Schedule","","","","","160.00","Fee Schedule","","","52","","223.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","115.98","52","","","Percent of Total Billed Charges","neg_dollar:$115.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","115.98","52","","","Percent of Total Billed Charges","neg_dollar:$115.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","191.81","86","","","Percent of Total Billed Charges","neg_dollar:$191.81","156.12","70","","","Percent of Total Billed Charges","neg_dollar:$156.12","","52","","223.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","131.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$131.03;102% of Medicaid interim rate","167.28","75","","","Percent of Total Billed Charges","neg_dollar:$167.28","191.81","86","","","Percent of Total Billed Charges","neg_dollar:$191.81","156.12","70","","","Percent of Total Billed Charges","neg_dollar:$156.12","127.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$127.13;103.5% of Medicaid interim rate","223.04","150","","","Percent of Total Billed Charges","neg_dollar:$344.83;150% of Medicaid interim rate","178.43","80","","","Percent of Total Billed Charges","neg_dollar:$178.43;Percent of Total Billed Charges","205.19","92","","","Percent of Total Billed Charges","neg_dollar:$205.19","115.98","52","","","Percent of Total Billed Charges","neg_dollar:$115.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","223.04","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","115.00","223.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00641-6027-25","NDC","250","RC","","Facility","Outpatient","2","ML","91.75","91.75","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","91.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.90","86","","","Percent of Total Billed Charges","neg_dollar:$78.90","64.22","70","","","Percent of Total Billed Charges","neg_dollar:$64.22","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.90;102% of Medicaid interim rate","68.81","75","","","Percent of Total Billed Charges","neg_dollar:$68.81","78.90","86","","","Percent of Total Billed Charges","neg_dollar:$78.90","64.22","70","","","Percent of Total Billed Charges","neg_dollar:$64.22","52.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.29;103.5% of Medicaid interim rate","91.75","150","","","Percent of Total Billed Charges","neg_dollar:$141.85;150% of Medicaid interim rate","73.40","80","","","Percent of Total Billed Charges","neg_dollar:$73.40;Percent of Total Billed Charges","84.41","92","","","Percent of Total Billed Charges","neg_dollar:$84.41","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00641-6027-25","NDC","636","RC","","Facility","Outpatient","2","ML","91.75","91.75","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.90","86","","","Percent of Total Billed Charges","neg_dollar:$78.90","64.22","70","","","Percent of Total Billed Charges","neg_dollar:$64.22","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.90;102% of Medicaid interim rate","68.81","75","","","Percent of Total Billed Charges","neg_dollar:$68.81","78.90","86","","","Percent of Total Billed Charges","neg_dollar:$78.90","64.22","70","","","Percent of Total Billed Charges","neg_dollar:$64.22","52.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.29;103.5% of Medicaid interim rate","91.75","150","","","Percent of Total Billed Charges","neg_dollar:$141.85;150% of Medicaid interim rate","73.40","80","","","Percent of Total Billed Charges","neg_dollar:$73.40;Percent of Total Billed Charges","84.41","92","","","Percent of Total Billed Charges","neg_dollar:$84.41","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00409-9094-12","NDC","250","RC","","Facility","Outpatient","2","ML","88.45","88.45","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","88.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.99","52","","","Percent of Total Billed Charges","neg_dollar:$45.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.99","52","","","Percent of Total Billed Charges","neg_dollar:$45.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.06","86","","","Percent of Total Billed Charges","neg_dollar:$76.06","61.91","70","","","Percent of Total Billed Charges","neg_dollar:$61.91","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","51.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.96;102% of Medicaid interim rate","66.33","75","","","Percent of Total Billed Charges","neg_dollar:$66.33","76.06","86","","","Percent of Total Billed Charges","neg_dollar:$76.06","61.91","70","","","Percent of Total Billed Charges","neg_dollar:$61.91","50.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.41;103.5% of Medicaid interim rate","88.45","150","","","Percent of Total Billed Charges","neg_dollar:$136.74;150% of Medicaid interim rate","70.76","80","","","Percent of Total Billed Charges","neg_dollar:$70.76;Percent of Total Billed Charges","81.37","92","","","Percent of Total Billed Charges","neg_dollar:$81.37","45.99","52","","","Percent of Total Billed Charges","neg_dollar:$45.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00409-9094-12","NDC","636","RC","","Facility","Outpatient","2","ML","89.36","89.36","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.85","86","","","Percent of Total Billed Charges","neg_dollar:$76.85","62.55","70","","","Percent of Total Billed Charges","neg_dollar:$62.55","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.50;102% of Medicaid interim rate","67.02","75","","","Percent of Total Billed Charges","neg_dollar:$67.02","76.85","86","","","Percent of Total Billed Charges","neg_dollar:$76.85","62.55","70","","","Percent of Total Billed Charges","neg_dollar:$62.55","50.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.93;103.5% of Medicaid interim rate","89.36","150","","","Percent of Total Billed Charges","neg_dollar:$138.16;150% of Medicaid interim rate","71.49","80","","","Percent of Total Billed Charges","neg_dollar:$71.49;Percent of Total Billed Charges","82.21","92","","","Percent of Total Billed Charges","neg_dollar:$82.21","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","89.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00641-6027-25","NDC","636","RC","","Facility","Outpatient","2","ML","90.20","90.20","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.90","52","","","Percent of Total Billed Charges","neg_dollar:$46.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","77.57","86","","","Percent of Total Billed Charges","neg_dollar:$77.57","63.14","70","","","Percent of Total Billed Charges","neg_dollar:$63.14","46.90","52","","","Percent of Total Billed Charges","neg_dollar:$46.90;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.99;102% of Medicaid interim rate","67.65","75","","","Percent of Total Billed Charges","neg_dollar:$67.65","77.57","86","","","Percent of Total Billed Charges","neg_dollar:$77.57","63.14","70","","","Percent of Total Billed Charges","neg_dollar:$63.14","51.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.41;103.5% of Medicaid interim rate","90.20","150","","","Percent of Total Billed Charges","neg_dollar:$139.46;150% of Medicaid interim rate","72.16","80","","","Percent of Total Billed Charges","neg_dollar:$72.16;Percent of Total Billed Charges","82.98","92","","","Percent of Total Billed Charges","neg_dollar:$82.98","46.90","52","","","Percent of Total Billed Charges","neg_dollar:$46.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.90","52","","","Percent of Total Billed Charges","neg_dollar:$46.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","90.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00641-6027-25","NDC","636","RC","","Facility","Outpatient","2","ML","91.58","91.58","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","47.62","52","","","Percent of Total Billed Charges","neg_dollar:$47.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.76","86","","","Percent of Total Billed Charges","neg_dollar:$78.76","64.11","70","","","Percent of Total Billed Charges","neg_dollar:$64.11","47.62","52","","","Percent of Total Billed Charges","neg_dollar:$47.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.80;102% of Medicaid interim rate","68.68","75","","","Percent of Total Billed Charges","neg_dollar:$68.68","78.76","86","","","Percent of Total Billed Charges","neg_dollar:$78.76","64.11","70","","","Percent of Total Billed Charges","neg_dollar:$64.11","52.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.20;103.5% of Medicaid interim rate","91.58","150","","","Percent of Total Billed Charges","neg_dollar:$141.59;150% of Medicaid interim rate","73.26","80","","","Percent of Total Billed Charges","neg_dollar:$73.26;Percent of Total Billed Charges","84.25","92","","","Percent of Total Billed Charges","neg_dollar:$84.25","47.62","52","","","Percent of Total Billed Charges","neg_dollar:$47.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.62","52","","","Percent of Total Billed Charges","neg_dollar:$47.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00641-6027-01","NDC","250","RC","","Facility","Outpatient","2","ML","91.48","91.48","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","91.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.57","52","","","Percent of Total Billed Charges","neg_dollar:$47.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.57","52","","","Percent of Total Billed Charges","neg_dollar:$47.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.67","86","","","Percent of Total Billed Charges","neg_dollar:$78.67","64.04","70","","","Percent of Total Billed Charges","neg_dollar:$64.04","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.74;102% of Medicaid interim rate","68.61","75","","","Percent of Total Billed Charges","neg_dollar:$68.61","78.67","86","","","Percent of Total Billed Charges","neg_dollar:$78.67","64.04","70","","","Percent of Total Billed Charges","neg_dollar:$64.04","52.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.14;103.5% of Medicaid interim rate","91.48","150","","","Percent of Total Billed Charges","neg_dollar:$141.44;150% of Medicaid interim rate","73.19","80","","","Percent of Total Billed Charges","neg_dollar:$73.19;Percent of Total Billed Charges","84.16","92","","","Percent of Total Billed Charges","neg_dollar:$84.16","47.57","52","","","Percent of Total Billed Charges","neg_dollar:$47.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00409-9094-12","NDC","250","RC","","Facility","Outpatient","2","ML","89.35","89.35","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","89.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.84","86","","","Percent of Total Billed Charges","neg_dollar:$76.84","62.54","70","","","Percent of Total Billed Charges","neg_dollar:$62.54","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.49;102% of Medicaid interim rate","67.01","75","","","Percent of Total Billed Charges","neg_dollar:$67.01","76.84","86","","","Percent of Total Billed Charges","neg_dollar:$76.84","62.54","70","","","Percent of Total Billed Charges","neg_dollar:$62.54","50.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.92;103.5% of Medicaid interim rate","89.35","150","","","Percent of Total Billed Charges","neg_dollar:$138.13;150% of Medicaid interim rate","71.48","80","","","Percent of Total Billed Charges","neg_dollar:$71.48;Percent of Total Billed Charges","82.20","92","","","Percent of Total Billed Charges","neg_dollar:$82.20","46.46","52","","","Percent of Total Billed Charges","neg_dollar:$46.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","89.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00641-6027-01","NDC","636","RC","","Facility","Outpatient","2","ML","91.20","91.20","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","47.42","52","","","Percent of Total Billed Charges","neg_dollar:$47.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.43","86","","","Percent of Total Billed Charges","neg_dollar:$78.43","63.84","70","","","Percent of Total Billed Charges","neg_dollar:$63.84","47.42","52","","","Percent of Total Billed Charges","neg_dollar:$47.42;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.58;102% of Medicaid interim rate","68.40","75","","","Percent of Total Billed Charges","neg_dollar:$68.40","78.43","86","","","Percent of Total Billed Charges","neg_dollar:$78.43","63.84","70","","","Percent of Total Billed Charges","neg_dollar:$63.84","51.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.98;103.5% of Medicaid interim rate","91.20","150","","","Percent of Total Billed Charges","neg_dollar:$141;150% of Medicaid interim rate","72.96","80","","","Percent of Total Billed Charges","neg_dollar:$72.96;Percent of Total Billed Charges","83.90","92","","","Percent of Total Billed Charges","neg_dollar:$83.90","47.42","52","","","Percent of Total Billed Charges","neg_dollar:$47.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.42","52","","","Percent of Total Billed Charges","neg_dollar:$47.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00409-9094-12","NDC","636","RC","","Facility","Outpatient","2","ML","89.12","89.12","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.34","52","","","Percent of Total Billed Charges","neg_dollar:$46.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.64","86","","","Percent of Total Billed Charges","neg_dollar:$76.64","62.38","70","","","Percent of Total Billed Charges","neg_dollar:$62.38","46.34","52","","","Percent of Total Billed Charges","neg_dollar:$46.34;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.36;102% of Medicaid interim rate","66.84","75","","","Percent of Total Billed Charges","neg_dollar:$66.84","76.64","86","","","Percent of Total Billed Charges","neg_dollar:$76.64","62.38","70","","","Percent of Total Billed Charges","neg_dollar:$62.38","50.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.80;103.5% of Medicaid interim rate","89.12","150","","","Percent of Total Billed Charges","neg_dollar:$137.79;150% of Medicaid interim rate","71.30","80","","","Percent of Total Billed Charges","neg_dollar:$71.30;Percent of Total Billed Charges","81.99","92","","","Percent of Total Billed Charges","neg_dollar:$81.99","46.34","52","","","Percent of Total Billed Charges","neg_dollar:$46.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.34","52","","","Percent of Total Billed Charges","neg_dollar:$46.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","89.00",""
"FENTANYL CITRATE (PF) 100 MCG/2ML IJ SOLN","J3010","HCPCS","00641-6027-01","NDC","636","RC","","Facility","Outpatient","2","ML","91.75","91.75","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","91.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.90","86","","","Percent of Total Billed Charges","neg_dollar:$78.90","64.22","70","","","Percent of Total Billed Charges","neg_dollar:$64.22","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;105% Medicare Outpatient Cost to Charge Ratio of 52%","53.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.90;102% of Medicaid interim rate","68.81","75","","","Percent of Total Billed Charges","neg_dollar:$68.81","78.90","86","","","Percent of Total Billed Charges","neg_dollar:$78.90","64.22","70","","","Percent of Total Billed Charges","neg_dollar:$64.22","52.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.29;103.5% of Medicaid interim rate","91.75","150","","","Percent of Total Billed Charges","neg_dollar:$141.85;150% of Medicaid interim rate","73.40","80","","","Percent of Total Billed Charges","neg_dollar:$73.40;Percent of Total Billed Charges","84.41","92","","","Percent of Total Billed Charges","neg_dollar:$84.41","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","47.71","52","","","Percent of Total Billed Charges","neg_dollar:$47.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","91.00",""
"FENTANYL CITRATE (PF) 250 MCG/5ML IJ SOLN","J3010","HCPCS","00409-9094-25","NDC","636","RC","","Facility","Outpatient","5","ML","30.71","30.71","","","","1.00","Fee Schedule","","","","","30.71","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","15.97","52","","","Percent of Total Billed Charges","neg_dollar:$15.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","30.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","30.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","26.41","86","","","Percent of Total Billed Charges","neg_dollar:$26.41","21.50","70","","","Percent of Total Billed Charges","neg_dollar:$21.50","15.97","52","","","Percent of Total Billed Charges","neg_dollar:$15.97;105% Medicare Outpatient Cost to Charge Ratio of 52%","18.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.04;102% of Medicaid interim rate","23.03","75","","","Percent of Total Billed Charges","neg_dollar:$23.03","26.41","86","","","Percent of Total Billed Charges","neg_dollar:$26.41","21.50","70","","","Percent of Total Billed Charges","neg_dollar:$21.50","17.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.50;103.5% of Medicaid interim rate","30.71","150","","","Percent of Total Billed Charges","neg_dollar:$47.48;150% of Medicaid interim rate","24.57","80","","","Percent of Total Billed Charges","neg_dollar:$24.57;Percent of Total Billed Charges","28.25","92","","","Percent of Total Billed Charges","neg_dollar:$28.25","15.97","52","","","Percent of Total Billed Charges","neg_dollar:$15.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","15.97","52","","","Percent of Total Billed Charges","neg_dollar:$15.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","30.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-01","NDC","250","RC","","Facility","Outpatient","1","ML","88.35","88.35","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","88.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.94","52","","","Percent of Total Billed Charges","neg_dollar:$45.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.94","52","","","Percent of Total Billed Charges","neg_dollar:$45.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","75.98","86","","","Percent of Total Billed Charges","neg_dollar:$75.98","61.84","70","","","Percent of Total Billed Charges","neg_dollar:$61.84","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","51.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.90;102% of Medicaid interim rate","66.26","75","","","Percent of Total Billed Charges","neg_dollar:$66.26","75.98","86","","","Percent of Total Billed Charges","neg_dollar:$75.98","61.84","70","","","Percent of Total Billed Charges","neg_dollar:$61.84","50.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.35;103.5% of Medicaid interim rate","88.35","150","","","Percent of Total Billed Charges","neg_dollar:$136.59;150% of Medicaid interim rate","70.67","80","","","Percent of Total Billed Charges","neg_dollar:$70.67;Percent of Total Billed Charges","81.28","92","","","Percent of Total Billed Charges","neg_dollar:$81.28","45.94","52","","","Percent of Total Billed Charges","neg_dollar:$45.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-11","NDC","636","RC","","Facility","Outpatient","1","ML","88.21","88.21","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","45.87","52","","","Percent of Total Billed Charges","neg_dollar:$45.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","75.86","86","","","Percent of Total Billed Charges","neg_dollar:$75.86","61.74","70","","","Percent of Total Billed Charges","neg_dollar:$61.74","45.87","52","","","Percent of Total Billed Charges","neg_dollar:$45.87;105% Medicare Outpatient Cost to Charge Ratio of 52%","51.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.82;102% of Medicaid interim rate","66.16","75","","","Percent of Total Billed Charges","neg_dollar:$66.16","75.86","86","","","Percent of Total Billed Charges","neg_dollar:$75.86","61.74","70","","","Percent of Total Billed Charges","neg_dollar:$61.74","50.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.28;103.5% of Medicaid interim rate","88.21","150","","","Percent of Total Billed Charges","neg_dollar:$136.38;150% of Medicaid interim rate","70.57","80","","","Percent of Total Billed Charges","neg_dollar:$70.57;Percent of Total Billed Charges","81.15","92","","","Percent of Total Billed Charges","neg_dollar:$81.15","45.87","52","","","Percent of Total Billed Charges","neg_dollar:$45.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.87","52","","","Percent of Total Billed Charges","neg_dollar:$45.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-01","NDC","636","RC","","Facility","Outpatient","1","ML","88.29","88.29","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","45.91","52","","","Percent of Total Billed Charges","neg_dollar:$45.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.29","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.29","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","75.93","86","","","Percent of Total Billed Charges","neg_dollar:$75.93","61.80","70","","","Percent of Total Billed Charges","neg_dollar:$61.80","45.91","52","","","Percent of Total Billed Charges","neg_dollar:$45.91;105% Medicare Outpatient Cost to Charge Ratio of 52%","51.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.87;102% of Medicaid interim rate","66.21","75","","","Percent of Total Billed Charges","neg_dollar:$66.21","75.93","86","","","Percent of Total Billed Charges","neg_dollar:$75.93","61.80","70","","","Percent of Total Billed Charges","neg_dollar:$61.80","50.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.32;103.5% of Medicaid interim rate","88.29","150","","","Percent of Total Billed Charges","neg_dollar:$136.50;150% of Medicaid interim rate","70.63","80","","","Percent of Total Billed Charges","neg_dollar:$70.63;Percent of Total Billed Charges","81.22","92","","","Percent of Total Billed Charges","neg_dollar:$81.22","45.91","52","","","Percent of Total Billed Charges","neg_dollar:$45.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.91","52","","","Percent of Total Billed Charges","neg_dollar:$45.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-11","NDC","636","RC","","Facility","Outpatient","1","ML","88.31","88.31","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","45.92","52","","","Percent of Total Billed Charges","neg_dollar:$45.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.31","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.31","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","75.95","86","","","Percent of Total Billed Charges","neg_dollar:$75.95","61.82","70","","","Percent of Total Billed Charges","neg_dollar:$61.82","45.92","52","","","Percent of Total Billed Charges","neg_dollar:$45.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","51.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.88;102% of Medicaid interim rate","66.23","75","","","Percent of Total Billed Charges","neg_dollar:$66.23","75.95","86","","","Percent of Total Billed Charges","neg_dollar:$75.95","61.82","70","","","Percent of Total Billed Charges","neg_dollar:$61.82","50.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.34;103.5% of Medicaid interim rate","88.31","150","","","Percent of Total Billed Charges","neg_dollar:$136.54;150% of Medicaid interim rate","70.65","80","","","Percent of Total Billed Charges","neg_dollar:$70.65;Percent of Total Billed Charges","81.25","92","","","Percent of Total Billed Charges","neg_dollar:$81.25","45.92","52","","","Percent of Total Billed Charges","neg_dollar:$45.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.92","52","","","Percent of Total Billed Charges","neg_dollar:$45.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-01","NDC","250","RC","","Facility","Outpatient","1","ML","88.08","88.08","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","88.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.80","52","","","Percent of Total Billed Charges","neg_dollar:$45.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.80","52","","","Percent of Total Billed Charges","neg_dollar:$45.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","75.75","86","","","Percent of Total Billed Charges","neg_dollar:$75.75","61.65","70","","","Percent of Total Billed Charges","neg_dollar:$61.65","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","51.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.74;102% of Medicaid interim rate","66.06","75","","","Percent of Total Billed Charges","neg_dollar:$66.06","75.75","86","","","Percent of Total Billed Charges","neg_dollar:$75.75","61.65","70","","","Percent of Total Billed Charges","neg_dollar:$61.65","50.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.20;103.5% of Medicaid interim rate","88.08","150","","","Percent of Total Billed Charges","neg_dollar:$136.18;150% of Medicaid interim rate","70.46","80","","","Percent of Total Billed Charges","neg_dollar:$70.46;Percent of Total Billed Charges","81.03","92","","","Percent of Total Billed Charges","neg_dollar:$81.03","45.80","52","","","Percent of Total Billed Charges","neg_dollar:$45.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","00409-9094-12","NDC","636","RC","","Facility","Outpatient","1","ML","88","88.00","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","45.76","52","","","Percent of Total Billed Charges","neg_dollar:$45.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","75.67","86","","","Percent of Total Billed Charges","neg_dollar:$75.67","61.59","70","","","Percent of Total Billed Charges","neg_dollar:$61.59","45.76","52","","","Percent of Total Billed Charges","neg_dollar:$45.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","51.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.69;102% of Medicaid interim rate","66.00","75","","","Percent of Total Billed Charges","neg_dollar:$66","75.67","86","","","Percent of Total Billed Charges","neg_dollar:$75.67","61.59","70","","","Percent of Total Billed Charges","neg_dollar:$61.59","50.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.16;103.5% of Medicaid interim rate","88.00","150","","","Percent of Total Billed Charges","neg_dollar:$136.05;150% of Medicaid interim rate","70.40","80","","","Percent of Total Billed Charges","neg_dollar:$70.40;Percent of Total Billed Charges","80.96","92","","","Percent of Total Billed Charges","neg_dollar:$80.96","45.76","52","","","Percent of Total Billed Charges","neg_dollar:$45.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.76","52","","","Percent of Total Billed Charges","neg_dollar:$45.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-11","NDC","250","RC","","Facility","Outpatient","1","ML","88.31","88.31","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","88.31","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.92","52","","","Percent of Total Billed Charges","neg_dollar:$45.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.92","52","","","Percent of Total Billed Charges","neg_dollar:$45.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","75.95","86","","","Percent of Total Billed Charges","neg_dollar:$75.95","61.82","70","","","Percent of Total Billed Charges","neg_dollar:$61.82","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","51.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.88;102% of Medicaid interim rate","66.23","75","","","Percent of Total Billed Charges","neg_dollar:$66.23","75.95","86","","","Percent of Total Billed Charges","neg_dollar:$75.95","61.82","70","","","Percent of Total Billed Charges","neg_dollar:$61.82","50.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.34;103.5% of Medicaid interim rate","88.31","150","","","Percent of Total Billed Charges","neg_dollar:$136.54;150% of Medicaid interim rate","70.65","80","","","Percent of Total Billed Charges","neg_dollar:$70.65;Percent of Total Billed Charges","81.25","92","","","Percent of Total Billed Charges","neg_dollar:$81.25","45.92","52","","","Percent of Total Billed Charges","neg_dollar:$45.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-01","NDC","636","RC","","Facility","Outpatient","1","ML","88.35","88.35","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","45.94","52","","","Percent of Total Billed Charges","neg_dollar:$45.94;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","75.98","86","","","Percent of Total Billed Charges","neg_dollar:$75.98","61.84","70","","","Percent of Total Billed Charges","neg_dollar:$61.84","45.94","52","","","Percent of Total Billed Charges","neg_dollar:$45.94;105% Medicare Outpatient Cost to Charge Ratio of 52%","51.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.90;102% of Medicaid interim rate","66.26","75","","","Percent of Total Billed Charges","neg_dollar:$66.26","75.98","86","","","Percent of Total Billed Charges","neg_dollar:$75.98","61.84","70","","","Percent of Total Billed Charges","neg_dollar:$61.84","50.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.35;103.5% of Medicaid interim rate","88.35","150","","","Percent of Total Billed Charges","neg_dollar:$136.59;150% of Medicaid interim rate","70.67","80","","","Percent of Total Billed Charges","neg_dollar:$70.67;Percent of Total Billed Charges","81.28","92","","","Percent of Total Billed Charges","neg_dollar:$81.28","45.94","52","","","Percent of Total Billed Charges","neg_dollar:$45.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.94","52","","","Percent of Total Billed Charges","neg_dollar:$45.94;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-11","NDC","636","RC","","Facility","Outpatient","1","ML","87.95","87.95","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","45.73","52","","","Percent of Total Billed Charges","neg_dollar:$45.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","87.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","87.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","75.63","86","","","Percent of Total Billed Charges","neg_dollar:$75.63","61.56","70","","","Percent of Total Billed Charges","neg_dollar:$61.56","45.73","52","","","Percent of Total Billed Charges","neg_dollar:$45.73;105% Medicare Outpatient Cost to Charge Ratio of 52%","51.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.67;102% of Medicaid interim rate","65.96","75","","","Percent of Total Billed Charges","neg_dollar:$65.96","75.63","86","","","Percent of Total Billed Charges","neg_dollar:$75.63","61.56","70","","","Percent of Total Billed Charges","neg_dollar:$61.56","50.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.13;103.5% of Medicaid interim rate","87.95","150","","","Percent of Total Billed Charges","neg_dollar:$135.97;150% of Medicaid interim rate","70.36","80","","","Percent of Total Billed Charges","neg_dollar:$70.36;Percent of Total Billed Charges","80.91","92","","","Percent of Total Billed Charges","neg_dollar:$80.91","45.73","52","","","Percent of Total Billed Charges","neg_dollar:$45.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.73","52","","","Percent of Total Billed Charges","neg_dollar:$45.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","87.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-01","NDC","636","RC","","Facility","Outpatient","1","ML","88.21","88.21","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","45.87","52","","","Percent of Total Billed Charges","neg_dollar:$45.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","88.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","75.86","86","","","Percent of Total Billed Charges","neg_dollar:$75.86","61.75","70","","","Percent of Total Billed Charges","neg_dollar:$61.75","45.87","52","","","Percent of Total Billed Charges","neg_dollar:$45.87;105% Medicare Outpatient Cost to Charge Ratio of 52%","51.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.82;102% of Medicaid interim rate","66.16","75","","","Percent of Total Billed Charges","neg_dollar:$66.16","75.86","86","","","Percent of Total Billed Charges","neg_dollar:$75.86","61.75","70","","","Percent of Total Billed Charges","neg_dollar:$61.75","50.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.28;103.5% of Medicaid interim rate","88.21","150","","","Percent of Total Billed Charges","neg_dollar:$136.38;150% of Medicaid interim rate","70.57","80","","","Percent of Total Billed Charges","neg_dollar:$70.57;Percent of Total Billed Charges","81.15","92","","","Percent of Total Billed Charges","neg_dollar:$81.15","45.87","52","","","Percent of Total Billed Charges","neg_dollar:$45.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.87","52","","","Percent of Total Billed Charges","neg_dollar:$45.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-11","NDC","250","RC","","Facility","Outpatient","1","ML","88.18","88.18","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","88.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.85","52","","","Percent of Total Billed Charges","neg_dollar:$45.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.85","52","","","Percent of Total Billed Charges","neg_dollar:$45.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","75.83","86","","","Percent of Total Billed Charges","neg_dollar:$75.83","61.72","70","","","Percent of Total Billed Charges","neg_dollar:$61.72","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","51.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.80;102% of Medicaid interim rate","66.13","75","","","Percent of Total Billed Charges","neg_dollar:$66.13","75.83","86","","","Percent of Total Billed Charges","neg_dollar:$75.83","61.72","70","","","Percent of Total Billed Charges","neg_dollar:$61.72","50.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.26;103.5% of Medicaid interim rate","88.18","150","","","Percent of Total Billed Charges","neg_dollar:$136.33;150% of Medicaid interim rate","70.54","80","","","Percent of Total Billed Charges","neg_dollar:$70.54;Percent of Total Billed Charges","81.12","92","","","Percent of Total Billed Charges","neg_dollar:$81.12","45.85","52","","","Percent of Total Billed Charges","neg_dollar:$45.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","88.00",""
"FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN","J3010","HCPCS","63323-806-11","NDC","250","RC","","Facility","Outpatient","1","ML","87.95","87.95","","","","1.00","Fee Schedule","","","","","38.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","87.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","45.73","52","","","Percent of Total Billed Charges","neg_dollar:$45.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.73","52","","","Percent of Total Billed Charges","neg_dollar:$45.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","75.63","86","","","Percent of Total Billed Charges","neg_dollar:$75.63","61.56","70","","","Percent of Total Billed Charges","neg_dollar:$61.56","","52","","71.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","51.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.67;102% of Medicaid interim rate","65.96","75","","","Percent of Total Billed Charges","neg_dollar:$65.96","75.63","86","","","Percent of Total Billed Charges","neg_dollar:$75.63","61.56","70","","","Percent of Total Billed Charges","neg_dollar:$61.56","50.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.13;103.5% of Medicaid interim rate","87.95","150","","","Percent of Total Billed Charges","neg_dollar:$135.97;150% of Medicaid interim rate","70.36","80","","","Percent of Total Billed Charges","neg_dollar:$70.36;Percent of Total Billed Charges","80.91","92","","","Percent of Total Billed Charges","neg_dollar:$80.91","45.73","52","","","Percent of Total Billed Charges","neg_dollar:$45.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","87.00",""
"TENECTEPLASE 50 MG IV KIT","J3101","HCPCS","50242-120-47","NDC","636","RC","","Facility","Outpatient","1","EA","93.82","93.82","","","","93.82","Fee Schedule","","","","","93.82","Fee Schedule","101% of Medicare Fee Schedule","","","","93.82","Fee Schedule","","48.78","52","","","Percent of Total Billed Charges","neg_dollar:$48.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","93.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","93.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","80.68","86","","","Percent of Total Billed Charges","neg_dollar:$80.68","65.67","70","","","Percent of Total Billed Charges","neg_dollar:$65.67","48.78","52","","","Percent of Total Billed Charges","neg_dollar:$48.78;105% Medicare Outpatient Cost to Charge Ratio of 52%","55.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.12;102% of Medicaid interim rate","70.36","75","","","Percent of Total Billed Charges","neg_dollar:$70.36","80.68","86","","","Percent of Total Billed Charges","neg_dollar:$80.68","65.67","70","","","Percent of Total Billed Charges","neg_dollar:$65.67","53.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.47;103.5% of Medicaid interim rate","93.82","150","","","Percent of Total Billed Charges","neg_dollar:$145.05;150% of Medicaid interim rate","75.05","80","","","Percent of Total Billed Charges","neg_dollar:$75.05;Percent of Total Billed Charges","86.31","92","","","Percent of Total Billed Charges","neg_dollar:$86.31","48.78","52","","","Percent of Total Billed Charges","neg_dollar:$48.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.78","52","","","Percent of Total Billed Charges","neg_dollar:$48.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","48.00","93.00",""
"TENECTEPLASE 50 MG IV KIT","J3101","HCPCS","50242-120-47","NDC","636","RC","","Facility","Outpatient","1","EA","191.58","191.58","","","","191.58","Fee Schedule","","","","","191.58","Fee Schedule","101% of Medicare Fee Schedule","","","","191.58","Fee Schedule","","99.62","52","","","Percent of Total Billed Charges","neg_dollar:$99.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","191.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","191.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","164.76","86","","","Percent of Total Billed Charges","neg_dollar:$164.76","134.10","70","","","Percent of Total Billed Charges","neg_dollar:$134.10","99.62","52","","","Percent of Total Billed Charges","neg_dollar:$99.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","112.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$112.55;102% of Medicaid interim rate","143.68","75","","","Percent of Total Billed Charges","neg_dollar:$143.68","164.76","86","","","Percent of Total Billed Charges","neg_dollar:$164.76","134.10","70","","","Percent of Total Billed Charges","neg_dollar:$134.10","109.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$109.20;103.5% of Medicaid interim rate","191.58","150","","","Percent of Total Billed Charges","neg_dollar:$296.19;150% of Medicaid interim rate","153.26","80","","","Percent of Total Billed Charges","neg_dollar:$153.26;Percent of Total Billed Charges","176.25","92","","","Percent of Total Billed Charges","neg_dollar:$176.25","99.62","52","","","Percent of Total Billed Charges","neg_dollar:$99.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","99.62","52","","","Percent of Total Billed Charges","neg_dollar:$99.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","99.00","191.00",""
"ROMOSOZUMAB-AQQG 105 MG/1.17ML SC SOSY","J3111","HCPCS","55513-998-02","NDC","636","RC","","Facility","Outpatient","1","UN","26.20","26.20","","","","26.20","Fee Schedule","","","","","26.20","Fee Schedule","101% of Medicare Fee Schedule","","","","26.20","Fee Schedule","","13.62","52","","","Percent of Total Billed Charges","neg_dollar:$13.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.53","86","","","Percent of Total Billed Charges","neg_dollar:$22.53","18.34","70","","","Percent of Total Billed Charges","neg_dollar:$18.34","13.62","52","","","Percent of Total Billed Charges","neg_dollar:$13.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","15.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.39;102% of Medicaid interim rate","19.65","75","","","Percent of Total Billed Charges","neg_dollar:$19.65","22.53","86","","","Percent of Total Billed Charges","neg_dollar:$22.53","18.34","70","","","Percent of Total Billed Charges","neg_dollar:$18.34","14.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.93;103.5% of Medicaid interim rate","26.20","150","","","Percent of Total Billed Charges","neg_dollar:$40.50;150% of Medicaid interim rate","20.96","80","","","Percent of Total Billed Charges","neg_dollar:$20.96;Percent of Total Billed Charges","24.10","92","","","Percent of Total Billed Charges","neg_dollar:$24.10","13.62","52","","","Percent of Total Billed Charges","neg_dollar:$13.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.62","52","","","Percent of Total Billed Charges","neg_dollar:$13.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","26.00",""
"ROMOSOZUMAB-AQQG 105 MG/1.17ML SC SOSY","J3111","HCPCS","55513-998-01","NDC","636","RC","","Facility","Outpatient","1","UN","24.26","24.26","","","","24.26","Fee Schedule","","","","","24.26","Fee Schedule","101% of Medicare Fee Schedule","","","","24.26","Fee Schedule","","12.61","52","","","Percent of Total Billed Charges","neg_dollar:$12.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.86","86","","","Percent of Total Billed Charges","neg_dollar:$20.86","16.98","70","","","Percent of Total Billed Charges","neg_dollar:$16.98","12.61","52","","","Percent of Total Billed Charges","neg_dollar:$12.61;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.25;102% of Medicaid interim rate","18.19","75","","","Percent of Total Billed Charges","neg_dollar:$18.19","20.86","86","","","Percent of Total Billed Charges","neg_dollar:$20.86","16.98","70","","","Percent of Total Billed Charges","neg_dollar:$16.98","13.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.82;103.5% of Medicaid interim rate","24.26","150","","","Percent of Total Billed Charges","neg_dollar:$37.51;150% of Medicaid interim rate","19.40","80","","","Percent of Total Billed Charges","neg_dollar:$19.40;Percent of Total Billed Charges","22.32","92","","","Percent of Total Billed Charges","neg_dollar:$22.32","12.61","52","","","Percent of Total Billed Charges","neg_dollar:$12.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.61","52","","","Percent of Total Billed Charges","neg_dollar:$12.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","24.00",""
"TILDRAKIZUMAB-ASMN 100 MG/ML SC SOSY","J3245","HCPCS","47335-177-95","NDC","636","RC","","Facility","Outpatient","1","UN","360.06","360.06","","","","360.06","Fee Schedule","","","","","360.06","Fee Schedule","101% of Medicare Fee Schedule","","","","360.06","Fee Schedule","","187.23","52","","","Percent of Total Billed Charges","neg_dollar:$187.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","360.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","360.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","309.65","86","","","Percent of Total Billed Charges","neg_dollar:$309.65","252.04","70","","","Percent of Total Billed Charges","neg_dollar:$252.04","187.23","52","","","Percent of Total Billed Charges","neg_dollar:$187.23;105% Medicare Outpatient Cost to Charge Ratio of 52%","211.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$211.54;102% of Medicaid interim rate","270.05","75","","","Percent of Total Billed Charges","neg_dollar:$270.05","309.65","86","","","Percent of Total Billed Charges","neg_dollar:$309.65","252.04","70","","","Percent of Total Billed Charges","neg_dollar:$252.04","205.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$205.23;103.5% of Medicaid interim rate","360.06","150","","","Percent of Total Billed Charges","neg_dollar:$556.68;150% of Medicaid interim rate","288.05","80","","","Percent of Total Billed Charges","neg_dollar:$288.05;Percent of Total Billed Charges","331.26","92","","","Percent of Total Billed Charges","neg_dollar:$331.26","187.23","52","","","Percent of Total Billed Charges","neg_dollar:$187.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","187.23","52","","","Percent of Total Billed Charges","neg_dollar:$187.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","187.00","360.00",""
"TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP","J3301","HCPCS","00703-0241-01","NDC","636","RC","","Facility","Outpatient","1","UN","21.41","21.41","","","","5.00","Fee Schedule","","","","","21.41","Fee Schedule","101% of Medicare Fee Schedule","","","","5.00","Fee Schedule","","11.13","52","","","Percent of Total Billed Charges","neg_dollar:$11.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","21.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","21.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","18.41","86","","","Percent of Total Billed Charges","neg_dollar:$18.41","14.98","70","","","Percent of Total Billed Charges","neg_dollar:$14.98","11.13","52","","","Percent of Total Billed Charges","neg_dollar:$11.13;105% Medicare Outpatient Cost to Charge Ratio of 52%","12.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.57;102% of Medicaid interim rate","16.05","75","","","Percent of Total Billed Charges","neg_dollar:$16.05","18.41","86","","","Percent of Total Billed Charges","neg_dollar:$18.41","14.98","70","","","Percent of Total Billed Charges","neg_dollar:$14.98","12.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.20;103.5% of Medicaid interim rate","21.41","150","","","Percent of Total Billed Charges","neg_dollar:$33.10;150% of Medicaid interim rate","17.12","80","","","Percent of Total Billed Charges","neg_dollar:$17.12;Percent of Total Billed Charges","19.69","92","","","Percent of Total Billed Charges","neg_dollar:$19.69","11.13","52","","","Percent of Total Billed Charges","neg_dollar:$11.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","11.13","52","","","Percent of Total Billed Charges","neg_dollar:$11.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","21.00",""
"TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP","J3301","HCPCS","00703-0241-01","NDC","636","RC","","Facility","Outpatient","1","UN","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","101% of Medicare Fee Schedule","","","","2.05","Fee Schedule","","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"DIAZEPAM 5 MG/ML IJ SOLN","J3360","HCPCS","00409-1273-32","NDC","250","RC","","Facility","Outpatient","1","UN","121.20","121.20","","","","42.00","Fee Schedule","","","","","59.00","Fee Schedule","","","","","7.00","Fee Schedule","","","52","","121.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","63.02","52","","","Percent of Total Billed Charges","neg_dollar:$63.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","63.02","52","","","Percent of Total Billed Charges","neg_dollar:$63.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.23","86","","","Percent of Total Billed Charges","neg_dollar:$104.23","84.84","70","","","Percent of Total Billed Charges","neg_dollar:$84.84","","52","","92.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","71.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.20;102% of Medicaid interim rate","90.90","75","","","Percent of Total Billed Charges","neg_dollar:$90.90","104.23","86","","","Percent of Total Billed Charges","neg_dollar:$104.23","84.84","70","","","Percent of Total Billed Charges","neg_dollar:$84.84","69.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$69.08;103.5% of Medicaid interim rate","121.20","150","","","Percent of Total Billed Charges","neg_dollar:$187.38;150% of Medicaid interim rate","96.96","80","","","Percent of Total Billed Charges","neg_dollar:$96.96;Percent of Total Billed Charges","111.50","92","","","Percent of Total Billed Charges","neg_dollar:$111.50","63.02","52","","","Percent of Total Billed Charges","neg_dollar:$63.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","70.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","121.00",""
"DIAZEPAM 5 MG/ML IJ SOLN","J3360","HCPCS","00409-1273-03","NDC","250","RC","","Facility","Outpatient","1","UN","114.46","114.46","","","","42.00","Fee Schedule","","","","","59.00","Fee Schedule","","","","","7.00","Fee Schedule","","","52","","114.46","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","59.51","52","","","Percent of Total Billed Charges","neg_dollar:$59.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","59.51","52","","","Percent of Total Billed Charges","neg_dollar:$59.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","98.43","86","","","Percent of Total Billed Charges","neg_dollar:$98.43","80.12","70","","","Percent of Total Billed Charges","neg_dollar:$80.12","","52","","92.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","67.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$67.24;102% of Medicaid interim rate","85.84","75","","","Percent of Total Billed Charges","neg_dollar:$85.84","98.43","86","","","Percent of Total Billed Charges","neg_dollar:$98.43","80.12","70","","","Percent of Total Billed Charges","neg_dollar:$80.12","65.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$65.24;103.5% of Medicaid interim rate","114.46","150","","","Percent of Total Billed Charges","neg_dollar:$176.96;150% of Medicaid interim rate","91.56","80","","","Percent of Total Billed Charges","neg_dollar:$91.56;Percent of Total Billed Charges","105.30","92","","","Percent of Total Billed Charges","neg_dollar:$105.30","59.51","52","","","Percent of Total Billed Charges","neg_dollar:$59.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","70.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","114.00",""
"DIAZEPAM 5 MG/ML IJ SOLN","J3360","HCPCS","00409-1273-03","NDC","636","RC","","Facility","Outpatient","1","UN","112.40","112.40","","","","42.00","Fee Schedule","","","","","59.00","Fee Schedule","101% of Medicare Fee Schedule","","","","7.00","Fee Schedule","","58.44","52","","","Percent of Total Billed Charges","neg_dollar:$58.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","112.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","112.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","96.66","86","","","Percent of Total Billed Charges","neg_dollar:$96.66","78.68","70","","","Percent of Total Billed Charges","neg_dollar:$78.68","58.44","52","","","Percent of Total Billed Charges","neg_dollar:$58.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","66.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.03;102% of Medicaid interim rate","84.30","75","","","Percent of Total Billed Charges","neg_dollar:$84.30","96.66","86","","","Percent of Total Billed Charges","neg_dollar:$96.66","78.68","70","","","Percent of Total Billed Charges","neg_dollar:$78.68","64.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.06;103.5% of Medicaid interim rate","112.40","150","","","Percent of Total Billed Charges","neg_dollar:$173.77;150% of Medicaid interim rate","89.92","80","","","Percent of Total Billed Charges","neg_dollar:$89.92;Percent of Total Billed Charges","103.40","92","","","Percent of Total Billed Charges","neg_dollar:$103.40","58.44","52","","","Percent of Total Billed Charges","neg_dollar:$58.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.44","52","","","Percent of Total Billed Charges","neg_dollar:$58.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","112.00",""
"VANCOMYCIN HCL 1 G IV SOLR","J3370","HCPCS","67457-340-01","NDC","250","RC","","Facility","Outpatient","2","UN","55.35","55.35","","","","50.00","Fee Schedule","","","","","55.35","Fee Schedule","","","","","9.00","Fee Schedule","","","52","","55.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.78","52","","","Percent of Total Billed Charges","neg_dollar:$28.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.78","52","","","Percent of Total Billed Charges","neg_dollar:$28.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.60","86","","","Percent of Total Billed Charges","neg_dollar:$47.60","38.74","70","","","Percent of Total Billed Charges","neg_dollar:$38.74","","52","","55.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","32.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.51;102% of Medicaid interim rate","41.51","75","","","Percent of Total Billed Charges","neg_dollar:$41.51","47.60","86","","","Percent of Total Billed Charges","neg_dollar:$47.60","38.74","70","","","Percent of Total Billed Charges","neg_dollar:$38.74","31.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.55;103.5% of Medicaid interim rate","55.35","150","","","Percent of Total Billed Charges","neg_dollar:$85.57;150% of Medicaid interim rate","44.28","80","","","Percent of Total Billed Charges","neg_dollar:$44.28;Percent of Total Billed Charges","50.92","92","","","Percent of Total Billed Charges","neg_dollar:$50.92","28.78","52","","","Percent of Total Billed Charges","neg_dollar:$28.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.35","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","55.00",""
"VANCOMYCIN HCL 1 G IV SOLR","J3370","HCPCS","67457-340-01","NDC","636","RC","","Facility","Outpatient","3","UN","39.26","39.26","","","","39.26","Fee Schedule","","","","","39.26","Fee Schedule","101% of Medicare Fee Schedule","","","","9.00","Fee Schedule","","20.41","52","","","Percent of Total Billed Charges","neg_dollar:$20.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","39.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","39.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","33.76","86","","","Percent of Total Billed Charges","neg_dollar:$33.76","27.48","70","","","Percent of Total Billed Charges","neg_dollar:$27.48","20.41","52","","","Percent of Total Billed Charges","neg_dollar:$20.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","23.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$23.06;102% of Medicaid interim rate","29.44","75","","","Percent of Total Billed Charges","neg_dollar:$29.44","33.76","86","","","Percent of Total Billed Charges","neg_dollar:$33.76","27.48","70","","","Percent of Total Billed Charges","neg_dollar:$27.48","22.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.37;103.5% of Medicaid interim rate","39.26","150","","","Percent of Total Billed Charges","neg_dollar:$60.70;150% of Medicaid interim rate","31.40","80","","","Percent of Total Billed Charges","neg_dollar:$31.40;Percent of Total Billed Charges","36.12","92","","","Percent of Total Billed Charges","neg_dollar:$36.12","20.41","52","","","Percent of Total Billed Charges","neg_dollar:$20.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","20.41","52","","","Percent of Total Billed Charges","neg_dollar:$20.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","39.00",""
"VANCOMYCIN HCL 1.5 G IV SOLR","J3370","HCPCS","00409-3515-11","NDC","636","RC","","Facility","Outpatient","4","UN","45.40","45.40","","","","45.40","Fee Schedule","","","","","45.40","Fee Schedule","101% of Medicare Fee Schedule","","","","9.00","Fee Schedule","","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","45.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","45.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","39.04","86","","","Percent of Total Billed Charges","neg_dollar:$39.04","31.77","70","","","Percent of Total Billed Charges","neg_dollar:$31.77","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","26.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.67;102% of Medicaid interim rate","34.05","75","","","Percent of Total Billed Charges","neg_dollar:$34.05","39.04","86","","","Percent of Total Billed Charges","neg_dollar:$39.04","31.77","70","","","Percent of Total Billed Charges","neg_dollar:$31.77","25.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.87;103.5% of Medicaid interim rate","45.40","150","","","Percent of Total Billed Charges","neg_dollar:$70.19;150% of Medicaid interim rate","36.32","80","","","Percent of Total Billed Charges","neg_dollar:$36.32;Percent of Total Billed Charges","41.76","92","","","Percent of Total Billed Charges","neg_dollar:$41.76","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","45.00",""
"VANCOMYCIN HCL 1.5 G IV SOLR","J3370","HCPCS","00409-3515-11","NDC","250","RC","","Facility","Outpatient","5","UN","45.40","45.40","","","","45.40","Fee Schedule","","","","","45.40","Fee Schedule","","","","","9.00","Fee Schedule","","","52","","45.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","39.04","86","","","Percent of Total Billed Charges","neg_dollar:$39.04","31.77","70","","","Percent of Total Billed Charges","neg_dollar:$31.77","","52","","45.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","26.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.67;102% of Medicaid interim rate","34.05","75","","","Percent of Total Billed Charges","neg_dollar:$34.05","39.04","86","","","Percent of Total Billed Charges","neg_dollar:$39.04","31.77","70","","","Percent of Total Billed Charges","neg_dollar:$31.77","25.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.87;103.5% of Medicaid interim rate","45.40","150","","","Percent of Total Billed Charges","neg_dollar:$70.19;150% of Medicaid interim rate","36.32","80","","","Percent of Total Billed Charges","neg_dollar:$36.32;Percent of Total Billed Charges","41.76","92","","","Percent of Total Billed Charges","neg_dollar:$41.76","23.60","52","","","Percent of Total Billed Charges","neg_dollar:$23.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","45.40","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","45.00",""
"VANCOMYCIN HCL 1.5 G IV SOLR","J3370","HCPCS","00409-3515-01","NDC","250","RC","","Facility","Outpatient","6","UN","45.41","45.41","","","","45.41","Fee Schedule","","","","","45.41","Fee Schedule","","","","","9.00","Fee Schedule","","","52","","45.41","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","23.61","52","","","Percent of Total Billed Charges","neg_dollar:$23.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.61","52","","","Percent of Total Billed Charges","neg_dollar:$23.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","39.05","86","","","Percent of Total Billed Charges","neg_dollar:$39.05","31.79","70","","","Percent of Total Billed Charges","neg_dollar:$31.79","","52","","45.41","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","26.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.68;102% of Medicaid interim rate","34.06","75","","","Percent of Total Billed Charges","neg_dollar:$34.06","39.05","86","","","Percent of Total Billed Charges","neg_dollar:$39.05","31.79","70","","","Percent of Total Billed Charges","neg_dollar:$31.79","25.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.88;103.5% of Medicaid interim rate","45.41","150","","","Percent of Total Billed Charges","neg_dollar:$70.21;150% of Medicaid interim rate","36.33","80","","","Percent of Total Billed Charges","neg_dollar:$36.33;Percent of Total Billed Charges","41.78","92","","","Percent of Total Billed Charges","neg_dollar:$41.78","23.61","52","","","Percent of Total Billed Charges","neg_dollar:$23.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","45.41","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","45.00",""
"VANCOMYCIN HCL 500 MG IV SOLR","J3370","HCPCS","67457-339-50","NDC","250","RC","","Facility","Outpatient","7","UN","103.60","103.60","","","","50.00","Fee Schedule","","","","","69.00","Fee Schedule","","","","","9.00","Fee Schedule","","","52","","103.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","53.87","52","","","Percent of Total Billed Charges","neg_dollar:$53.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","53.87","52","","","Percent of Total Billed Charges","neg_dollar:$53.87;102% Medicare Outpatient Cost to Charge Ratio of 52%","89.09","86","","","Percent of Total Billed Charges","neg_dollar:$89.09","72.52","70","","","Percent of Total Billed Charges","neg_dollar:$72.52","","52","","103.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","60.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$60.86;102% of Medicaid interim rate","77.69","75","","","Percent of Total Billed Charges","neg_dollar:$77.69","89.09","86","","","Percent of Total Billed Charges","neg_dollar:$89.09","72.52","70","","","Percent of Total Billed Charges","neg_dollar:$72.52","59.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.05;103.5% of Medicaid interim rate","103.60","150","","","Percent of Total Billed Charges","neg_dollar:$160.17;150% of Medicaid interim rate","82.88","80","","","Percent of Total Billed Charges","neg_dollar:$82.88;Percent of Total Billed Charges","95.31","92","","","Percent of Total Billed Charges","neg_dollar:$95.31","53.87","52","","","Percent of Total Billed Charges","neg_dollar:$53.87;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","82.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","103.00",""
"VANCOMYCIN HCL 750 MG IV SOLR","J3370","HCPCS","63323-203-20","NDC","636","RC","","Facility","Outpatient","8","UN","38.66","38.66","","","","38.66","Fee Schedule","","","","","38.66","Fee Schedule","101% of Medicare Fee Schedule","","","","9.00","Fee Schedule","","20.10","52","","","Percent of Total Billed Charges","neg_dollar:$20.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","38.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","38.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","33.25","86","","","Percent of Total Billed Charges","neg_dollar:$33.25","27.06","70","","","Percent of Total Billed Charges","neg_dollar:$27.06","20.10","52","","","Percent of Total Billed Charges","neg_dollar:$20.10;105% Medicare Outpatient Cost to Charge Ratio of 52%","22.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.71;102% of Medicaid interim rate","28.99","75","","","Percent of Total Billed Charges","neg_dollar:$28.99","33.25","86","","","Percent of Total Billed Charges","neg_dollar:$33.25","27.06","70","","","Percent of Total Billed Charges","neg_dollar:$27.06","22.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.03;103.5% of Medicaid interim rate","38.66","150","","","Percent of Total Billed Charges","neg_dollar:$59.78;150% of Medicaid interim rate","30.93","80","","","Percent of Total Billed Charges","neg_dollar:$30.93;Percent of Total Billed Charges","35.57","92","","","Percent of Total Billed Charges","neg_dollar:$35.57","20.10","52","","","Percent of Total Billed Charges","neg_dollar:$20.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","20.10","52","","","Percent of Total Billed Charges","neg_dollar:$20.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","38.00",""
"VANCOMYCIN HCL 1.25 G IV SOLR","J3371","HCPCS","67457-823-12","NDC","636","RC","","Facility","Outpatient","9","UN","42.56","42.56","","","","42.56","Fee Schedule","","","","","42.56","Fee Schedule","101% of Medicare Fee Schedule","","","","42.56","Fee Schedule","","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","42.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","42.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","36.60","86","","","Percent of Total Billed Charges","neg_dollar:$36.60","29.79","70","","","Percent of Total Billed Charges","neg_dollar:$29.79","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;105% Medicare Outpatient Cost to Charge Ratio of 52%","25.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$25;102% of Medicaid interim rate","31.92","75","","","Percent of Total Billed Charges","neg_dollar:$31.92","36.60","86","","","Percent of Total Billed Charges","neg_dollar:$36.60","29.79","70","","","Percent of Total Billed Charges","neg_dollar:$29.79","24.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.26;103.5% of Medicaid interim rate","42.56","150","","","Percent of Total Billed Charges","neg_dollar:$65.81;150% of Medicaid interim rate","34.05","80","","","Percent of Total Billed Charges","neg_dollar:$34.05;Percent of Total Billed Charges","39.16","92","","","Percent of Total Billed Charges","neg_dollar:$39.16","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","22.00","42.00",""
"VANCOMYCIN HCL 1.25 G IV SOLR","J3371","HCPCS","67457-823-12","NDC","250","RC","","Facility","Outpatient","10","UN","42.56","42.56","","","","42.56","Fee Schedule","","","","","42.56","Fee Schedule","","","","","42.56","Fee Schedule","","","52","","42.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","36.60","86","","","Percent of Total Billed Charges","neg_dollar:$36.60","29.79","70","","","Percent of Total Billed Charges","neg_dollar:$29.79","","52","","42.56","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","25.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$25;102% of Medicaid interim rate","31.92","75","","","Percent of Total Billed Charges","neg_dollar:$31.92","36.60","86","","","Percent of Total Billed Charges","neg_dollar:$36.60","29.79","70","","","Percent of Total Billed Charges","neg_dollar:$29.79","24.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.26;103.5% of Medicaid interim rate","42.56","150","","","Percent of Total Billed Charges","neg_dollar:$65.81;150% of Medicaid interim rate","34.05","80","","","Percent of Total Billed Charges","neg_dollar:$34.05;Percent of Total Billed Charges","39.16","92","","","Percent of Total Billed Charges","neg_dollar:$39.16","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","42.56","Fee Schedule","","22.00","42.00",""
"VANCOMYCIN HCL 1.25 G IV SOLR","J3371","HCPCS","67457-823-99","NDC","250","RC","","Facility","Outpatient","11","UN","42.56","42.56","","","","42.56","Fee Schedule","","","","","42.56","Fee Schedule","","","","","42.56","Fee Schedule","","","52","","42.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","36.60","86","","","Percent of Total Billed Charges","neg_dollar:$36.60","29.79","70","","","Percent of Total Billed Charges","neg_dollar:$29.79","","52","","42.56","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","25.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$25;102% of Medicaid interim rate","31.92","75","","","Percent of Total Billed Charges","neg_dollar:$31.92","36.60","86","","","Percent of Total Billed Charges","neg_dollar:$36.60","29.79","70","","","Percent of Total Billed Charges","neg_dollar:$29.79","24.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.26;103.5% of Medicaid interim rate","42.56","150","","","Percent of Total Billed Charges","neg_dollar:$65.81;150% of Medicaid interim rate","34.05","80","","","Percent of Total Billed Charges","neg_dollar:$34.05;Percent of Total Billed Charges","39.16","92","","","Percent of Total Billed Charges","neg_dollar:$39.16","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","42.56","Fee Schedule","","22.00","42.00",""
"VANCOMYCIN HCL 1.25 G IV SOLR","J3371","HCPCS","67457-823-99","NDC","636","RC","","Facility","Outpatient","12","UN","42.56","42.56","","","","42.56","Fee Schedule","","","","","42.56","Fee Schedule","101% of Medicare Fee Schedule","","","","42.56","Fee Schedule","","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","42.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","42.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","36.60","86","","","Percent of Total Billed Charges","neg_dollar:$36.60","29.79","70","","","Percent of Total Billed Charges","neg_dollar:$29.79","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;105% Medicare Outpatient Cost to Charge Ratio of 52%","25.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$25;102% of Medicaid interim rate","31.92","75","","","Percent of Total Billed Charges","neg_dollar:$31.92","36.60","86","","","Percent of Total Billed Charges","neg_dollar:$36.60","29.79","70","","","Percent of Total Billed Charges","neg_dollar:$29.79","24.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.26;103.5% of Medicaid interim rate","42.56","150","","","Percent of Total Billed Charges","neg_dollar:$65.81;150% of Medicaid interim rate","34.05","80","","","Percent of Total Billed Charges","neg_dollar:$34.05;Percent of Total Billed Charges","39.16","92","","","Percent of Total Billed Charges","neg_dollar:$39.16","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","22.13","52","","","Percent of Total Billed Charges","neg_dollar:$22.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","22.00","42.00",""
"VANCOMYCIN HCL 750 MG IV SOLR","J3371","HCPCS","67457-705-00","NDC","250","RC","","Facility","Outpatient","13","UN","9.70","9.70","","","","9.70","Fee Schedule","","","","","9.70","Fee Schedule","","","","","9.70","Fee Schedule","","","52","","9.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.04","52","","","Percent of Total Billed Charges","neg_dollar:$5.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.04","52","","","Percent of Total Billed Charges","neg_dollar:$5.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.34","86","","","Percent of Total Billed Charges","neg_dollar:$8.34","6.78","70","","","Percent of Total Billed Charges","neg_dollar:$6.78","","52","","9.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.69;102% of Medicaid interim rate","7.27","75","","","Percent of Total Billed Charges","neg_dollar:$7.27","8.34","86","","","Percent of Total Billed Charges","neg_dollar:$8.34","6.78","70","","","Percent of Total Billed Charges","neg_dollar:$6.78","5.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.52;103.5% of Medicaid interim rate","9.70","150","","","Percent of Total Billed Charges","neg_dollar:$14.99;150% of Medicaid interim rate","7.76","80","","","Percent of Total Billed Charges","neg_dollar:$7.76;Percent of Total Billed Charges","8.92","92","","","Percent of Total Billed Charges","neg_dollar:$8.92","5.04","52","","","Percent of Total Billed Charges","neg_dollar:$5.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","9.70","Fee Schedule","","5.00","9.00",""
"VANCOMYCIN HCL 2000 MG/400ML IV SOLN","J3372","HCPCS","70594-044-01","NDC","636","RC","","Facility","Outpatient","14","UN","35.87","35.87","","","","35.87","Fee Schedule","","","","","35.87","Fee Schedule","101% of Medicare Fee Schedule","","","","35.87","Fee Schedule","","18.65","52","","","Percent of Total Billed Charges","neg_dollar:$18.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","35.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","35.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","30.85","86","","","Percent of Total Billed Charges","neg_dollar:$30.85","25.11","70","","","Percent of Total Billed Charges","neg_dollar:$25.11","18.65","52","","","Percent of Total Billed Charges","neg_dollar:$18.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","21.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.07;102% of Medicaid interim rate","26.90","75","","","Percent of Total Billed Charges","neg_dollar:$26.90","30.85","86","","","Percent of Total Billed Charges","neg_dollar:$30.85","25.11","70","","","Percent of Total Billed Charges","neg_dollar:$25.11","20.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.44;103.5% of Medicaid interim rate","35.87","150","","","Percent of Total Billed Charges","neg_dollar:$55.46;150% of Medicaid interim rate","28.70","80","","","Percent of Total Billed Charges","neg_dollar:$28.70;Percent of Total Billed Charges","33.00","92","","","Percent of Total Billed Charges","neg_dollar:$33","18.65","52","","","Percent of Total Billed Charges","neg_dollar:$18.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","18.65","52","","","Percent of Total Billed Charges","neg_dollar:$18.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","18.00","35.00",""
"VANCOMYCIN HCL 2000 MG/400ML IV SOLN","J3372","HCPCS","70594-044-01","NDC","250","RC","","Facility","Outpatient","15","UN","35.87","35.87","","","","35.87","Fee Schedule","","","","","35.87","Fee Schedule","","","","","35.87","Fee Schedule","","","52","","35.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","18.65","52","","","Percent of Total Billed Charges","neg_dollar:$18.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.65","52","","","Percent of Total Billed Charges","neg_dollar:$18.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.85","86","","","Percent of Total Billed Charges","neg_dollar:$30.85","25.11","70","","","Percent of Total Billed Charges","neg_dollar:$25.11","","52","","35.87","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","21.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.07;102% of Medicaid interim rate","26.90","75","","","Percent of Total Billed Charges","neg_dollar:$26.90","30.85","86","","","Percent of Total Billed Charges","neg_dollar:$30.85","25.11","70","","","Percent of Total Billed Charges","neg_dollar:$25.11","20.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.44;103.5% of Medicaid interim rate","35.87","150","","","Percent of Total Billed Charges","neg_dollar:$55.46;150% of Medicaid interim rate","28.70","80","","","Percent of Total Billed Charges","neg_dollar:$28.70;Percent of Total Billed Charges","33.00","92","","","Percent of Total Billed Charges","neg_dollar:$33","18.65","52","","","Percent of Total Billed Charges","neg_dollar:$18.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","35.87","Fee Schedule","","18.00","35.00",""
"VANCOMYCIN HCL 1.5 G IV SOLR","J3373","HCPCS","00409-3515-11","NDC","636","RC","","Facility","Outpatient","16","UN","0.90","0.90","","","","0.90","Fee Schedule","","","","","0.90","Fee Schedule","101% of Medicare Fee Schedule","","","","0.90","Fee Schedule","","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% of Medicaid interim rate","0.68","75","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.90","150","","","Percent of Total Billed Charges","neg_dollar:$1.40;150% of Medicaid interim rate","0.72","80","","","Percent of Total Billed Charges","neg_dollar:$0.72;Percent of Total Billed Charges","0.83","92","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"VANCOMYCIN HCL 1.5 G IV SOLR","J3373","HCPCS","00409-3515-11","NDC","250","RC","","Facility","Outpatient","17","UN","0.90","0.90","","","","0.90","Fee Schedule","","","","","0.90","Fee Schedule","","","","","0.90","Fee Schedule","","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","","52","","0.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% of Medicaid interim rate","0.68","75","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.90","150","","","Percent of Total Billed Charges","neg_dollar:$1.40;150% of Medicaid interim rate","0.72","80","","","Percent of Total Billed Charges","neg_dollar:$0.72;Percent of Total Billed Charges","0.83","92","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.90","Fee Schedule","","1.00","1.00",""
"VANCOMYCIN HCL 750 MG IV SOLR","J3373","HCPCS","63323-203-20","NDC","636","RC","","Facility","Outpatient","18","UN","1.42","1.42","","","","1.42","Fee Schedule","","","","","1.42","Fee Schedule","101% of Medicare Fee Schedule","","","","1.42","Fee Schedule","","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.42","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.22","86","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","70","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% of Medicaid interim rate","1.06","75","","","Percent of Total Billed Charges","neg_dollar:$1.06","1.22","86","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","70","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.80;103.5% of Medicaid interim rate","1.42","150","","","Percent of Total Billed Charges","neg_dollar:$2.19;150% of Medicaid interim rate","1.13","80","","","Percent of Total Billed Charges","neg_dollar:$1.13;Percent of Total Billed Charges","1.30","92","","","Percent of Total Billed Charges","neg_dollar:$1.30","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","52","","","Percent of Total Billed Charges","neg_dollar:$0.73;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"VANCOMYCIN HCL 1 G IV SOLR","J3374","HCPCS","67457-340-01","NDC","636","RC","","Facility","Outpatient","19","UN","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","101% of Medicare Fee Schedule","","","","1.05","Fee Schedule","","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"VANCOMYCIN HCL 1.25 G IV SOLR","J3374","HCPCS","67457-823-12","NDC","636","RC","","Facility","Outpatient","20","UN","1.02","1.02","","","","1.02","Fee Schedule","","","","","1.02","Fee Schedule","101% of Medicare Fee Schedule","","","","1.02","Fee Schedule","","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","86","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","70","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% of Medicaid interim rate","0.76","75","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.87","86","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","70","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;103.5% of Medicaid interim rate","1.02","150","","","Percent of Total Billed Charges","neg_dollar:$1.57;150% of Medicaid interim rate","0.81","80","","","Percent of Total Billed Charges","neg_dollar:$0.81;Percent of Total Billed Charges","0.93","92","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"VANCOMYCIN HCL 500 MG IV SOLR","J3374","HCPCS","67457-339-50","NDC","636","RC","","Facility","Outpatient","21","UN","2.07","2.07","","","","2.07","Fee Schedule","","","","","2.07","Fee Schedule","101% of Medicare Fee Schedule","","","","2.07","Fee Schedule","","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.78","86","","","Percent of Total Billed Charges","neg_dollar:$1.78","1.45","70","","","Percent of Total Billed Charges","neg_dollar:$1.45","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.21;102% of Medicaid interim rate","1.55","75","","","Percent of Total Billed Charges","neg_dollar:$1.55","1.78","86","","","Percent of Total Billed Charges","neg_dollar:$1.78","1.45","70","","","Percent of Total Billed Charges","neg_dollar:$1.45","1.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.18;103.5% of Medicaid interim rate","2.07","150","","","Percent of Total Billed Charges","neg_dollar:$3.20;150% of Medicaid interim rate","1.65","80","","","Percent of Total Billed Charges","neg_dollar:$1.65;Percent of Total Billed Charges","1.90","92","","","Percent of Total Billed Charges","neg_dollar:$1.90","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","52","","","Percent of Total Billed Charges","neg_dollar:$1.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"VANCOMYCIN HCL 2000 MG/400ML IV SOLN","J3375","HCPCS","70594-044-01","NDC","636","RC","","Facility","Outpatient","22","UN","0.71","0.71","","","","0.71","Fee Schedule","","","","","0.71","Fee Schedule","101% of Medicare Fee Schedule","","","","0.71","Fee Schedule","","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","86","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% of Medicaid interim rate","0.53","75","","","Percent of Total Billed Charges","neg_dollar:$0.53","0.61","86","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.40;103.5% of Medicaid interim rate","0.71","150","","","Percent of Total Billed Charges","neg_dollar:$1.10;150% of Medicaid interim rate","0.57","80","","","Percent of Total Billed Charges","neg_dollar:$0.57;Percent of Total Billed Charges","0.66","92","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"VEDOLIZUMAB 300 MG IV SOLR","J3380","HCPCS","64764-300-20","NDC","636","RC","","Facility","Outpatient","300","ME","56.05","56.05","","","","56.05","Fee Schedule","","","","","56.05","Fee Schedule","101% of Medicare Fee Schedule","","","","56.05","Fee Schedule","","29.14","52","","","Percent of Total Billed Charges","neg_dollar:$29.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","56.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","56.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","48.20","86","","","Percent of Total Billed Charges","neg_dollar:$48.20","39.23","70","","","Percent of Total Billed Charges","neg_dollar:$39.23","29.14","52","","","Percent of Total Billed Charges","neg_dollar:$29.14;105% Medicare Outpatient Cost to Charge Ratio of 52%","32.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.93;102% of Medicaid interim rate","42.04","75","","","Percent of Total Billed Charges","neg_dollar:$42.04","48.20","86","","","Percent of Total Billed Charges","neg_dollar:$48.20","39.23","70","","","Percent of Total Billed Charges","neg_dollar:$39.23","31.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.95;103.5% of Medicaid interim rate","56.05","150","","","Percent of Total Billed Charges","neg_dollar:$86.66;150% of Medicaid interim rate","44.84","80","","","Percent of Total Billed Charges","neg_dollar:$44.84;Percent of Total Billed Charges","51.57","92","","","Percent of Total Billed Charges","neg_dollar:$51.57","29.14","52","","","Percent of Total Billed Charges","neg_dollar:$29.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","29.14","52","","","Percent of Total Billed Charges","neg_dollar:$29.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","29.00","56.00",""
"VEDOLIZUMAB 300 MG IV SOLR","J3380","HCPCS","64764-300-20","NDC","636","RC","","Facility","Outpatient","300","ME","56.45","56.45","","","","56.45","Fee Schedule","","","","","56.45","Fee Schedule","101% of Medicare Fee Schedule","","","","56.45","Fee Schedule","","29.35","52","","","Percent of Total Billed Charges","neg_dollar:$29.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","56.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","56.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","48.55","86","","","Percent of Total Billed Charges","neg_dollar:$48.55","39.51","70","","","Percent of Total Billed Charges","neg_dollar:$39.51","29.35","52","","","Percent of Total Billed Charges","neg_dollar:$29.35;105% Medicare Outpatient Cost to Charge Ratio of 52%","33.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.16;102% of Medicaid interim rate","42.34","75","","","Percent of Total Billed Charges","neg_dollar:$42.34","48.55","86","","","Percent of Total Billed Charges","neg_dollar:$48.55","39.51","70","","","Percent of Total Billed Charges","neg_dollar:$39.51","32.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.17;103.5% of Medicaid interim rate","56.45","150","","","Percent of Total Billed Charges","neg_dollar:$87.28;150% of Medicaid interim rate","45.16","80","","","Percent of Total Billed Charges","neg_dollar:$45.16;Percent of Total Billed Charges","51.93","92","","","Percent of Total Billed Charges","neg_dollar:$51.93","29.35","52","","","Percent of Total Billed Charges","neg_dollar:$29.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","29.35","52","","","Percent of Total Billed Charges","neg_dollar:$29.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","29.00","56.00",""
"THIAMINE HCL 100 MG/ML IJ SOLN","J3411","HCPCS","63323-013-02","NDC","636","RC","","Facility","Outpatient","1","ML","97.45","97.45","","","","39.00","Fee Schedule","","","","","55.00","Fee Schedule","101% of Medicare Fee Schedule","","","","6.00","Fee Schedule","","50.67","52","","","Percent of Total Billed Charges","neg_dollar:$50.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","97.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","97.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","83.80","86","","","Percent of Total Billed Charges","neg_dollar:$83.80","68.21","70","","","Percent of Total Billed Charges","neg_dollar:$68.21","50.67","52","","","Percent of Total Billed Charges","neg_dollar:$50.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","57.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.25;102% of Medicaid interim rate","73.08","75","","","Percent of Total Billed Charges","neg_dollar:$73.08","83.80","86","","","Percent of Total Billed Charges","neg_dollar:$83.80","68.21","70","","","Percent of Total Billed Charges","neg_dollar:$68.21","55.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.54;103.5% of Medicaid interim rate","97.45","150","","","Percent of Total Billed Charges","neg_dollar:$150.66;150% of Medicaid interim rate","77.96","80","","","Percent of Total Billed Charges","neg_dollar:$77.96;Percent of Total Billed Charges","89.65","92","","","Percent of Total Billed Charges","neg_dollar:$89.65","50.67","52","","","Percent of Total Billed Charges","neg_dollar:$50.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","50.67","52","","","Percent of Total Billed Charges","neg_dollar:$50.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","97.00",""
"THIAMINE HCL 100 MG/ML IJ SOLN","J3411","HCPCS","63323-013-01","NDC","636","RC","","Facility","Outpatient","1","ML","65.63","65.63","","","","39.00","Fee Schedule","","","","","55.00","Fee Schedule","101% of Medicare Fee Schedule","","","","6.00","Fee Schedule","","34.12","52","","","Percent of Total Billed Charges","neg_dollar:$34.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","65.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","65.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","56.44","86","","","Percent of Total Billed Charges","neg_dollar:$56.44","45.94","70","","","Percent of Total Billed Charges","neg_dollar:$45.94","34.12","52","","","Percent of Total Billed Charges","neg_dollar:$34.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","38.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$38.55;102% of Medicaid interim rate","49.22","75","","","Percent of Total Billed Charges","neg_dollar:$49.22","56.44","86","","","Percent of Total Billed Charges","neg_dollar:$56.44","45.94","70","","","Percent of Total Billed Charges","neg_dollar:$45.94","37.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.41;103.5% of Medicaid interim rate","65.63","150","","","Percent of Total Billed Charges","neg_dollar:$101.47;150% of Medicaid interim rate","52.50","80","","","Percent of Total Billed Charges","neg_dollar:$52.50;Percent of Total Billed Charges","60.38","92","","","Percent of Total Billed Charges","neg_dollar:$60.38","34.12","52","","","Percent of Total Billed Charges","neg_dollar:$34.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","34.12","52","","","Percent of Total Billed Charges","neg_dollar:$34.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","65.00",""
"THIAMINE HCL 100 MG/ML IJ SOLN","J3411","HCPCS","63323-013-01","NDC","250","RC","","Facility","Outpatient","1","ML","97.45","97.45","","","","39.00","Fee Schedule","","","","","55.00","Fee Schedule","","","","","6.00","Fee Schedule","","","52","","97.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","50.67","52","","","Percent of Total Billed Charges","neg_dollar:$50.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.67","52","","","Percent of Total Billed Charges","neg_dollar:$50.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.80","86","","","Percent of Total Billed Charges","neg_dollar:$83.80","68.21","70","","","Percent of Total Billed Charges","neg_dollar:$68.21","","52","","85.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","57.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.25;102% of Medicaid interim rate","73.08","75","","","Percent of Total Billed Charges","neg_dollar:$73.08","83.80","86","","","Percent of Total Billed Charges","neg_dollar:$83.80","68.21","70","","","Percent of Total Billed Charges","neg_dollar:$68.21","55.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.54;103.5% of Medicaid interim rate","97.45","150","","","Percent of Total Billed Charges","neg_dollar:$150.66;150% of Medicaid interim rate","77.96","80","","","Percent of Total Billed Charges","neg_dollar:$77.96;Percent of Total Billed Charges","89.65","92","","","Percent of Total Billed Charges","neg_dollar:$89.65","50.67","52","","","Percent of Total Billed Charges","neg_dollar:$50.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","65.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","97.00",""
"CYANOCOBALAMIN 1000 MCG/ML IJ SOLN","J3420","HCPCS","00517-0031-25","NDC","250","RC","","Facility","Outpatient","1","ML","101.50","101.50","","","","37.00","Fee Schedule","","","","","52.00","Fee Schedule","","","","","40.00","Fee Schedule","","","52","","101.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","52.78","52","","","Percent of Total Billed Charges","neg_dollar:$52.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.78","52","","","Percent of Total Billed Charges","neg_dollar:$52.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","87.28","86","","","Percent of Total Billed Charges","neg_dollar:$87.28","71.05","70","","","Percent of Total Billed Charges","neg_dollar:$71.05","","52","","81.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","59.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.63;102% of Medicaid interim rate","76.12","75","","","Percent of Total Billed Charges","neg_dollar:$76.12","87.28","86","","","Percent of Total Billed Charges","neg_dollar:$87.28","71.05","70","","","Percent of Total Billed Charges","neg_dollar:$71.05","57.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.85;103.5% of Medicaid interim rate","101.50","150","","","Percent of Total Billed Charges","neg_dollar:$156.92;150% of Medicaid interim rate","81.20","80","","","Percent of Total Billed Charges","neg_dollar:$81.20;Percent of Total Billed Charges","93.38","92","","","Percent of Total Billed Charges","neg_dollar:$93.38","52.78","52","","","Percent of Total Billed Charges","neg_dollar:$52.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","61.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","37.00","101.00",""
"PHYTONADIONE 1 MG/0.5ML IJ SOLN","J3430","HCPCS","76329-1240-1","NDC","636","RC","","Facility","Outpatient","1","ME","87.03","87.03","","","","60.00","Fee Schedule","","","","","84.00","Fee Schedule","101% of Medicare Fee Schedule","","","","64.00","Fee Schedule","","45.25","52","","","Percent of Total Billed Charges","neg_dollar:$45.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","87.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","87.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","74.85","86","","","Percent of Total Billed Charges","neg_dollar:$74.85","60.92","70","","","Percent of Total Billed Charges","neg_dollar:$60.92","45.25","52","","","Percent of Total Billed Charges","neg_dollar:$45.25;105% Medicare Outpatient Cost to Charge Ratio of 52%","51.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.13;102% of Medicaid interim rate","65.27","75","","","Percent of Total Billed Charges","neg_dollar:$65.27","74.85","86","","","Percent of Total Billed Charges","neg_dollar:$74.85","60.92","70","","","Percent of Total Billed Charges","neg_dollar:$60.92","49.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$49.61;103.5% of Medicaid interim rate","87.03","150","","","Percent of Total Billed Charges","neg_dollar:$134.56;150% of Medicaid interim rate","69.63","80","","","Percent of Total Billed Charges","neg_dollar:$69.63;Percent of Total Billed Charges","80.07","92","","","Percent of Total Billed Charges","neg_dollar:$80.07","45.25","52","","","Percent of Total Billed Charges","neg_dollar:$45.25;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.25","52","","","Percent of Total Billed Charges","neg_dollar:$45.25;100% Medicare Outpatient Cost to Charge Ratio of 52%","45.00","87.00",""
"VITAMIN K1 10 MG/ML IJ SOLN","J3430","HCPCS","69097-708-31","NDC","636","RC","","Facility","Outpatient","1","ML","4.28","4.28","","","","4.28","Fee Schedule","","","","","4.28","Fee Schedule","101% of Medicare Fee Schedule","","","","4.28","Fee Schedule","","2.22","52","","","Percent of Total Billed Charges","neg_dollar:$2.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.68","86","","","Percent of Total Billed Charges","neg_dollar:$3.68","2.99","70","","","Percent of Total Billed Charges","neg_dollar:$2.99","2.22","52","","","Percent of Total Billed Charges","neg_dollar:$2.22;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.51;102% of Medicaid interim rate","3.21","75","","","Percent of Total Billed Charges","neg_dollar:$3.21","3.68","86","","","Percent of Total Billed Charges","neg_dollar:$3.68","2.99","70","","","Percent of Total Billed Charges","neg_dollar:$2.99","2.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.43;103.5% of Medicaid interim rate","4.28","150","","","Percent of Total Billed Charges","neg_dollar:$6.61;150% of Medicaid interim rate","3.42","80","","","Percent of Total Billed Charges","neg_dollar:$3.42;Percent of Total Billed Charges","3.93","92","","","Percent of Total Billed Charges","neg_dollar:$3.93","2.22","52","","","Percent of Total Billed Charges","neg_dollar:$2.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.22","52","","","Percent of Total Billed Charges","neg_dollar:$2.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"VITAMIN K1 10 MG/ML IJ SOLN","J3430","HCPCS","69097-708-96","NDC","636","RC","","Facility","Outpatient","1","ML","4.58","4.58","","","","4.58","Fee Schedule","","","","","4.58","Fee Schedule","101% of Medicare Fee Schedule","","","","4.58","Fee Schedule","","2.38","52","","","Percent of Total Billed Charges","neg_dollar:$2.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.94","86","","","Percent of Total Billed Charges","neg_dollar:$3.94","3.20","70","","","Percent of Total Billed Charges","neg_dollar:$3.20","2.38","52","","","Percent of Total Billed Charges","neg_dollar:$2.38;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.69;102% of Medicaid interim rate","3.43","75","","","Percent of Total Billed Charges","neg_dollar:$3.43","3.94","86","","","Percent of Total Billed Charges","neg_dollar:$3.94","3.20","70","","","Percent of Total Billed Charges","neg_dollar:$3.20","2.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.61;103.5% of Medicaid interim rate","4.58","150","","","Percent of Total Billed Charges","neg_dollar:$7.08;150% of Medicaid interim rate","3.66","80","","","Percent of Total Billed Charges","neg_dollar:$3.66;Percent of Total Billed Charges","4.21","92","","","Percent of Total Billed Charges","neg_dollar:$4.21","2.38","52","","","Percent of Total Billed Charges","neg_dollar:$2.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.38","52","","","Percent of Total Billed Charges","neg_dollar:$2.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"VITAMIN K1 10 MG/ML IJ SOLN","J3430","HCPCS","69097-708-31","NDC","250","RC","","Facility","Outpatient","1","ML","17.30","17.30","","","","17.30","Fee Schedule","","","","","17.30","Fee Schedule","","","","","17.30","Fee Schedule","","","52","","17.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.99","52","","","Percent of Total Billed Charges","neg_dollar:$8.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.99","52","","","Percent of Total Billed Charges","neg_dollar:$8.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.88","86","","","Percent of Total Billed Charges","neg_dollar:$14.88","12.11","70","","","Percent of Total Billed Charges","neg_dollar:$12.11","","52","","17.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.16;102% of Medicaid interim rate","12.97","75","","","Percent of Total Billed Charges","neg_dollar:$12.97","14.88","86","","","Percent of Total Billed Charges","neg_dollar:$14.88","12.11","70","","","Percent of Total Billed Charges","neg_dollar:$12.11","9.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.86;103.5% of Medicaid interim rate","17.30","150","","","Percent of Total Billed Charges","neg_dollar:$26.75;150% of Medicaid interim rate","13.84","80","","","Percent of Total Billed Charges","neg_dollar:$13.84;Percent of Total Billed Charges","15.92","92","","","Percent of Total Billed Charges","neg_dollar:$15.92","8.99","52","","","Percent of Total Billed Charges","neg_dollar:$8.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","17.30","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","17.00",""
"VITAMIN K1 10 MG/ML IJ SOLN","J3430","HCPCS","43598-405-11","NDC","636","RC","","Facility","Outpatient","1","ML","17.30","17.30","","","","17.30","Fee Schedule","","","","","17.30","Fee Schedule","101% of Medicare Fee Schedule","","","","17.30","Fee Schedule","","8.99","52","","","Percent of Total Billed Charges","neg_dollar:$8.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","17.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.88","86","","","Percent of Total Billed Charges","neg_dollar:$14.88","12.11","70","","","Percent of Total Billed Charges","neg_dollar:$12.11","8.99","52","","","Percent of Total Billed Charges","neg_dollar:$8.99;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.16;102% of Medicaid interim rate","12.97","75","","","Percent of Total Billed Charges","neg_dollar:$12.97","14.88","86","","","Percent of Total Billed Charges","neg_dollar:$14.88","12.11","70","","","Percent of Total Billed Charges","neg_dollar:$12.11","9.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.86;103.5% of Medicaid interim rate","17.30","150","","","Percent of Total Billed Charges","neg_dollar:$26.75;150% of Medicaid interim rate","13.84","80","","","Percent of Total Billed Charges","neg_dollar:$13.84;Percent of Total Billed Charges","15.92","92","","","Percent of Total Billed Charges","neg_dollar:$15.92","8.99","52","","","Percent of Total Billed Charges","neg_dollar:$8.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.99","52","","","Percent of Total Billed Charges","neg_dollar:$8.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","8.00","17.00",""
"VITAMIN K1 10 MG/ML IJ SOLN","J3430","HCPCS","69097-708-31","NDC","636","RC","","Facility","Outpatient","1","ML","20.22","20.22","","","","20.22","Fee Schedule","","","","","20.22","Fee Schedule","101% of Medicare Fee Schedule","","","","20.22","Fee Schedule","","10.51","52","","","Percent of Total Billed Charges","neg_dollar:$10.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","20.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.39","86","","","Percent of Total Billed Charges","neg_dollar:$17.39","14.15","70","","","Percent of Total Billed Charges","neg_dollar:$14.15","10.51","52","","","Percent of Total Billed Charges","neg_dollar:$10.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","11.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.88;102% of Medicaid interim rate","15.16","75","","","Percent of Total Billed Charges","neg_dollar:$15.16","17.39","86","","","Percent of Total Billed Charges","neg_dollar:$17.39","14.15","70","","","Percent of Total Billed Charges","neg_dollar:$14.15","11.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.52;103.5% of Medicaid interim rate","20.22","150","","","Percent of Total Billed Charges","neg_dollar:$31.26;150% of Medicaid interim rate","16.17","80","","","Percent of Total Billed Charges","neg_dollar:$16.17;Percent of Total Billed Charges","18.60","92","","","Percent of Total Billed Charges","neg_dollar:$18.60","10.51","52","","","Percent of Total Billed Charges","neg_dollar:$10.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.51","52","","","Percent of Total Billed Charges","neg_dollar:$10.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.00","20.00",""
"VITAMIN K1 10 MG/ML IJ SOLN","J3430","HCPCS","69097-708-96","NDC","636","RC","","Facility","Outpatient","1","ML","19.96","19.96","","","","19.96","Fee Schedule","","","","","19.96","Fee Schedule","101% of Medicare Fee Schedule","","","","19.96","Fee Schedule","","10.38","52","","","Percent of Total Billed Charges","neg_dollar:$10.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","19.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","19.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","17.17","86","","","Percent of Total Billed Charges","neg_dollar:$17.17","13.97","70","","","Percent of Total Billed Charges","neg_dollar:$13.97","10.38","52","","","Percent of Total Billed Charges","neg_dollar:$10.38;105% Medicare Outpatient Cost to Charge Ratio of 52%","11.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.73;102% of Medicaid interim rate","14.97","75","","","Percent of Total Billed Charges","neg_dollar:$14.97","17.17","86","","","Percent of Total Billed Charges","neg_dollar:$17.17","13.97","70","","","Percent of Total Billed Charges","neg_dollar:$13.97","11.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.38;103.5% of Medicaid interim rate","19.96","150","","","Percent of Total Billed Charges","neg_dollar:$30.87;150% of Medicaid interim rate","15.97","80","","","Percent of Total Billed Charges","neg_dollar:$15.97;Percent of Total Billed Charges","18.37","92","","","Percent of Total Billed Charges","neg_dollar:$18.37","10.38","52","","","Percent of Total Billed Charges","neg_dollar:$10.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.38","52","","","Percent of Total Billed Charges","neg_dollar:$10.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.00","19.00",""
"HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN","J3473","HCPCS","18657-117-01","NDC","636","RC","","Facility","Outpatient","1","ML","1.32","1.32","","","","1.32","Fee Schedule","","","","","1.32","Fee Schedule","101% of Medicare Fee Schedule","","","","1.32","Fee Schedule","","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","86","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.92","70","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% of Medicaid interim rate","0.99","75","","","Percent of Total Billed Charges","neg_dollar:$0.99","1.14","86","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.92","70","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.75;103.5% of Medicaid interim rate","1.32","150","","","Percent of Total Billed Charges","neg_dollar:$2.05;150% of Medicaid interim rate","1.06","80","","","Percent of Total Billed Charges","neg_dollar:$1.06;Percent of Total Billed Charges","1.22","92","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","00264-4204-52","NDC","636","RC","","Facility","Outpatient","1","UN","24.07","24.07","","","","24.07","Fee Schedule","","","","","24.07","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","12.51","52","","","Percent of Total Billed Charges","neg_dollar:$12.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.70","86","","","Percent of Total Billed Charges","neg_dollar:$20.70","16.85","70","","","Percent of Total Billed Charges","neg_dollar:$16.85","12.51","52","","","Percent of Total Billed Charges","neg_dollar:$12.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.14;102% of Medicaid interim rate","18.05","75","","","Percent of Total Billed Charges","neg_dollar:$18.05","20.70","86","","","Percent of Total Billed Charges","neg_dollar:$20.70","16.85","70","","","Percent of Total Billed Charges","neg_dollar:$16.85","13.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.72;103.5% of Medicaid interim rate","24.07","150","","","Percent of Total Billed Charges","neg_dollar:$37.22;150% of Medicaid interim rate","19.26","80","","","Percent of Total Billed Charges","neg_dollar:$19.26;Percent of Total Billed Charges","22.14","92","","","Percent of Total Billed Charges","neg_dollar:$22.14","12.51","52","","","Percent of Total Billed Charges","neg_dollar:$12.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.51","52","","","Percent of Total Billed Charges","neg_dollar:$12.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","24.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","83634-500-41","NDC","636","RC","","Facility","Outpatient","1","UN","24.47","24.47","","","","24.47","Fee Schedule","","","","","24.47","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","12.72","52","","","Percent of Total Billed Charges","neg_dollar:$12.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","21.04","86","","","Percent of Total Billed Charges","neg_dollar:$21.04","17.13","70","","","Percent of Total Billed Charges","neg_dollar:$17.13","12.72","52","","","Percent of Total Billed Charges","neg_dollar:$12.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.37;102% of Medicaid interim rate","18.35","75","","","Percent of Total Billed Charges","neg_dollar:$18.35","21.04","86","","","Percent of Total Billed Charges","neg_dollar:$21.04","17.13","70","","","Percent of Total Billed Charges","neg_dollar:$17.13","13.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.95;103.5% of Medicaid interim rate","24.47","150","","","Percent of Total Billed Charges","neg_dollar:$37.83;150% of Medicaid interim rate","19.58","80","","","Percent of Total Billed Charges","neg_dollar:$19.58;Percent of Total Billed Charges","22.51","92","","","Percent of Total Billed Charges","neg_dollar:$22.51","12.72","52","","","Percent of Total Billed Charges","neg_dollar:$12.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.72","52","","","Percent of Total Billed Charges","neg_dollar:$12.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","24.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","63323-106-02","NDC","636","RC","","Facility","Outpatient","1","UN","23.87","23.87","","","","23.87","Fee Schedule","","","","","23.87","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","12.41","52","","","Percent of Total Billed Charges","neg_dollar:$12.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.53","86","","","Percent of Total Billed Charges","neg_dollar:$20.53","16.71","70","","","Percent of Total Billed Charges","neg_dollar:$16.71","12.41","52","","","Percent of Total Billed Charges","neg_dollar:$12.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.02;102% of Medicaid interim rate","17.90","75","","","Percent of Total Billed Charges","neg_dollar:$17.90","20.53","86","","","Percent of Total Billed Charges","neg_dollar:$20.53","16.71","70","","","Percent of Total Billed Charges","neg_dollar:$16.71","13.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.60;103.5% of Medicaid interim rate","23.87","150","","","Percent of Total Billed Charges","neg_dollar:$36.91;150% of Medicaid interim rate","19.10","80","","","Percent of Total Billed Charges","neg_dollar:$19.10;Percent of Total Billed Charges","21.96","92","","","Percent of Total Billed Charges","neg_dollar:$21.96","12.41","52","","","Percent of Total Billed Charges","neg_dollar:$12.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.41","52","","","Percent of Total Billed Charges","neg_dollar:$12.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","23.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","00264-4204-52","NDC","250","RC","","Facility","Outpatient","1","UN","24.07","24.07","","","","24.07","Fee Schedule","","","","","24.07","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","24.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.51","52","","","Percent of Total Billed Charges","neg_dollar:$12.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.51","52","","","Percent of Total Billed Charges","neg_dollar:$12.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.70","86","","","Percent of Total Billed Charges","neg_dollar:$20.70","16.85","70","","","Percent of Total Billed Charges","neg_dollar:$16.85","","52","","24.07","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.14;102% of Medicaid interim rate","18.05","75","","","Percent of Total Billed Charges","neg_dollar:$18.05","20.70","86","","","Percent of Total Billed Charges","neg_dollar:$20.70","16.85","70","","","Percent of Total Billed Charges","neg_dollar:$16.85","13.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.72;103.5% of Medicaid interim rate","24.07","150","","","Percent of Total Billed Charges","neg_dollar:$37.22;150% of Medicaid interim rate","19.26","80","","","Percent of Total Billed Charges","neg_dollar:$19.26;Percent of Total Billed Charges","22.14","92","","","Percent of Total Billed Charges","neg_dollar:$22.14","12.51","52","","","Percent of Total Billed Charges","neg_dollar:$12.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","24.07","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","24.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","70121-1719-2","NDC","250","RC","","Facility","Outpatient","1","UN","28.12","28.12","","","","28.12","Fee Schedule","","","","","28.12","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","28.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.62","52","","","Percent of Total Billed Charges","neg_dollar:$14.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.62","52","","","Percent of Total Billed Charges","neg_dollar:$14.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.18","86","","","Percent of Total Billed Charges","neg_dollar:$24.18","19.68","70","","","Percent of Total Billed Charges","neg_dollar:$19.68","","52","","28.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","16.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.52;102% of Medicaid interim rate","21.09","75","","","Percent of Total Billed Charges","neg_dollar:$21.09","24.18","86","","","Percent of Total Billed Charges","neg_dollar:$24.18","19.68","70","","","Percent of Total Billed Charges","neg_dollar:$19.68","16.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.03;103.5% of Medicaid interim rate","28.12","150","","","Percent of Total Billed Charges","neg_dollar:$43.48;150% of Medicaid interim rate","22.50","80","","","Percent of Total Billed Charges","neg_dollar:$22.50;Percent of Total Billed Charges","25.87","92","","","Percent of Total Billed Charges","neg_dollar:$25.87","14.62","52","","","Percent of Total Billed Charges","neg_dollar:$14.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","28.12","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","28.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","70121-1719-9","NDC","250","RC","","Facility","Outpatient","1","UN","28.12","28.12","","","","28.12","Fee Schedule","","","","","28.12","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","28.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.62","52","","","Percent of Total Billed Charges","neg_dollar:$14.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.62","52","","","Percent of Total Billed Charges","neg_dollar:$14.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.18","86","","","Percent of Total Billed Charges","neg_dollar:$24.18","19.68","70","","","Percent of Total Billed Charges","neg_dollar:$19.68","","52","","28.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","16.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.52;102% of Medicaid interim rate","21.09","75","","","Percent of Total Billed Charges","neg_dollar:$21.09","24.18","86","","","Percent of Total Billed Charges","neg_dollar:$24.18","19.68","70","","","Percent of Total Billed Charges","neg_dollar:$19.68","16.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.03;103.5% of Medicaid interim rate","28.12","150","","","Percent of Total Billed Charges","neg_dollar:$43.48;150% of Medicaid interim rate","22.50","80","","","Percent of Total Billed Charges","neg_dollar:$22.50;Percent of Total Billed Charges","25.87","92","","","Percent of Total Billed Charges","neg_dollar:$25.87","14.62","52","","","Percent of Total Billed Charges","neg_dollar:$14.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","28.12","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","28.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","83634-500-41","NDC","636","RC","","Facility","Outpatient","1","UN","23.66","23.66","","","","23.66","Fee Schedule","","","","","23.66","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","12.30","52","","","Percent of Total Billed Charges","neg_dollar:$12.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.35","86","","","Percent of Total Billed Charges","neg_dollar:$20.35","16.56","70","","","Percent of Total Billed Charges","neg_dollar:$16.56","12.30","52","","","Percent of Total Billed Charges","neg_dollar:$12.30;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.90;102% of Medicaid interim rate","17.74","75","","","Percent of Total Billed Charges","neg_dollar:$17.74","20.35","86","","","Percent of Total Billed Charges","neg_dollar:$20.35","16.56","70","","","Percent of Total Billed Charges","neg_dollar:$16.56","13.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.48;103.5% of Medicaid interim rate","23.66","150","","","Percent of Total Billed Charges","neg_dollar:$36.58;150% of Medicaid interim rate","18.93","80","","","Percent of Total Billed Charges","neg_dollar:$18.93;Percent of Total Billed Charges","21.77","92","","","Percent of Total Billed Charges","neg_dollar:$21.77","12.30","52","","","Percent of Total Billed Charges","neg_dollar:$12.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.30","52","","","Percent of Total Billed Charges","neg_dollar:$12.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","23.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","44567-420-24","NDC","636","RC","","Facility","Outpatient","1","UN","24.92","24.92","","","","24.92","Fee Schedule","","","","","24.92","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","12.95","52","","","Percent of Total Billed Charges","neg_dollar:$12.95;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","24.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","21.43","86","","","Percent of Total Billed Charges","neg_dollar:$21.43","17.44","70","","","Percent of Total Billed Charges","neg_dollar:$17.44","12.95","52","","","Percent of Total Billed Charges","neg_dollar:$12.95;105% Medicare Outpatient Cost to Charge Ratio of 52%","14.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.64;102% of Medicaid interim rate","18.69","75","","","Percent of Total Billed Charges","neg_dollar:$18.69","21.43","86","","","Percent of Total Billed Charges","neg_dollar:$21.43","17.44","70","","","Percent of Total Billed Charges","neg_dollar:$17.44","14.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.20;103.5% of Medicaid interim rate","24.92","150","","","Percent of Total Billed Charges","neg_dollar:$38.53;150% of Medicaid interim rate","19.93","80","","","Percent of Total Billed Charges","neg_dollar:$19.93;Percent of Total Billed Charges","22.92","92","","","Percent of Total Billed Charges","neg_dollar:$22.92","12.95","52","","","Percent of Total Billed Charges","neg_dollar:$12.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.95","52","","","Percent of Total Billed Charges","neg_dollar:$12.95;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","24.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","70121-1719-2","NDC","636","RC","","Facility","Outpatient","1","UN","28.12","28.12","","","","28.12","Fee Schedule","","","","","28.12","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","14.62","52","","","Percent of Total Billed Charges","neg_dollar:$14.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","28.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","28.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","24.18","86","","","Percent of Total Billed Charges","neg_dollar:$24.18","19.68","70","","","Percent of Total Billed Charges","neg_dollar:$19.68","14.62","52","","","Percent of Total Billed Charges","neg_dollar:$14.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.52;102% of Medicaid interim rate","21.09","75","","","Percent of Total Billed Charges","neg_dollar:$21.09","24.18","86","","","Percent of Total Billed Charges","neg_dollar:$24.18","19.68","70","","","Percent of Total Billed Charges","neg_dollar:$19.68","16.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.03;103.5% of Medicaid interim rate","28.12","150","","","Percent of Total Billed Charges","neg_dollar:$43.48;150% of Medicaid interim rate","22.50","80","","","Percent of Total Billed Charges","neg_dollar:$22.50;Percent of Total Billed Charges","25.87","92","","","Percent of Total Billed Charges","neg_dollar:$25.87","14.62","52","","","Percent of Total Billed Charges","neg_dollar:$14.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.62","52","","","Percent of Total Billed Charges","neg_dollar:$14.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","28.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","70121-1719-9","NDC","636","RC","","Facility","Outpatient","1","UN","28.55","28.55","","","","28.55","Fee Schedule","","","","","28.55","Fee Schedule","101% of Medicare Fee Schedule","","","","3.00","Fee Schedule","","14.84","52","","","Percent of Total Billed Charges","neg_dollar:$14.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","28.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","28.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","24.55","86","","","Percent of Total Billed Charges","neg_dollar:$24.55","19.98","70","","","Percent of Total Billed Charges","neg_dollar:$19.98","14.84","52","","","Percent of Total Billed Charges","neg_dollar:$14.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.77;102% of Medicaid interim rate","21.41","75","","","Percent of Total Billed Charges","neg_dollar:$21.41","24.55","86","","","Percent of Total Billed Charges","neg_dollar:$24.55","19.98","70","","","Percent of Total Billed Charges","neg_dollar:$19.98","16.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.27;103.5% of Medicaid interim rate","28.55","150","","","Percent of Total Billed Charges","neg_dollar:$44.14;150% of Medicaid interim rate","22.84","80","","","Percent of Total Billed Charges","neg_dollar:$22.84;Percent of Total Billed Charges","26.26","92","","","Percent of Total Billed Charges","neg_dollar:$26.26","14.84","52","","","Percent of Total Billed Charges","neg_dollar:$14.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.84","52","","","Percent of Total Billed Charges","neg_dollar:$14.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","28.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","44567-420-24","NDC","250","RC","","Facility","Outpatient","1","UN","25.27","25.27","","","","25.27","Fee Schedule","","","","","25.27","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","25.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","13.14","52","","","Percent of Total Billed Charges","neg_dollar:$13.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.14","52","","","Percent of Total Billed Charges","neg_dollar:$13.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.73","86","","","Percent of Total Billed Charges","neg_dollar:$21.73","17.69","70","","","Percent of Total Billed Charges","neg_dollar:$17.69","","52","","25.27","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.84;102% of Medicaid interim rate","18.95","75","","","Percent of Total Billed Charges","neg_dollar:$18.95","21.73","86","","","Percent of Total Billed Charges","neg_dollar:$21.73","17.69","70","","","Percent of Total Billed Charges","neg_dollar:$17.69","14.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.40;103.5% of Medicaid interim rate","25.27","150","","","Percent of Total Billed Charges","neg_dollar:$39.07;150% of Medicaid interim rate","20.22","80","","","Percent of Total Billed Charges","neg_dollar:$20.22;Percent of Total Billed Charges","23.25","92","","","Percent of Total Billed Charges","neg_dollar:$23.25","13.14","52","","","Percent of Total Billed Charges","neg_dollar:$13.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","25.27","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","25.00",""
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN","J3475","HCPCS","83634-500-41","NDC","250","RC","","Facility","Outpatient","1","UN","24.47","24.47","","","","24.47","Fee Schedule","","","","","24.47","Fee Schedule","","","","","3.00","Fee Schedule","","","52","","24.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.72","52","","","Percent of Total Billed Charges","neg_dollar:$12.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.72","52","","","Percent of Total Billed Charges","neg_dollar:$12.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.04","86","","","Percent of Total Billed Charges","neg_dollar:$21.04","17.13","70","","","Percent of Total Billed Charges","neg_dollar:$17.13","","52","","24.47","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.37;102% of Medicaid interim rate","18.35","75","","","Percent of Total Billed Charges","neg_dollar:$18.35","21.04","86","","","Percent of Total Billed Charges","neg_dollar:$21.04","17.13","70","","","Percent of Total Billed Charges","neg_dollar:$17.13","13.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.95;103.5% of Medicaid interim rate","24.47","150","","","Percent of Total Billed Charges","neg_dollar:$37.83;150% of Medicaid interim rate","19.58","80","","","Percent of Total Billed Charges","neg_dollar:$19.58;Percent of Total Billed Charges","22.51","92","","","Percent of Total Billed Charges","neg_dollar:$22.51","12.72","52","","","Percent of Total Billed Charges","neg_dollar:$12.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","24.47","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","24.00",""
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN","J3480","HCPCS","00990-7075-26","NDC","636","RC","","Facility","Outpatient","1","UN","9.75","9.75","","","","9.75","Fee Schedule","","","","","9.75","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","5.07","52","","","Percent of Total Billed Charges","neg_dollar:$5.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.38","86","","","Percent of Total Billed Charges","neg_dollar:$8.38","6.82","70","","","Percent of Total Billed Charges","neg_dollar:$6.82","5.07","52","","","Percent of Total Billed Charges","neg_dollar:$5.07;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.72;102% of Medicaid interim rate","7.31","75","","","Percent of Total Billed Charges","neg_dollar:$7.31","8.38","86","","","Percent of Total Billed Charges","neg_dollar:$8.38","6.82","70","","","Percent of Total Billed Charges","neg_dollar:$6.82","5.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.55;103.5% of Medicaid interim rate","9.75","150","","","Percent of Total Billed Charges","neg_dollar:$15.07;150% of Medicaid interim rate","7.80","80","","","Percent of Total Billed Charges","neg_dollar:$7.80;Percent of Total Billed Charges","8.97","92","","","Percent of Total Billed Charges","neg_dollar:$8.97","5.07","52","","","Percent of Total Billed Charges","neg_dollar:$5.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.07","52","","","Percent of Total Billed Charges","neg_dollar:$5.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","9.00",""
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN","J3480","HCPCS","00990-7075-26","NDC","250","RC","","Facility","Outpatient","1","UN","9.75","9.75","","","","9.75","Fee Schedule","","","","","9.75","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","9.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.07","52","","","Percent of Total Billed Charges","neg_dollar:$5.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.07","52","","","Percent of Total Billed Charges","neg_dollar:$5.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.38","86","","","Percent of Total Billed Charges","neg_dollar:$8.38","6.82","70","","","Percent of Total Billed Charges","neg_dollar:$6.82","","52","","9.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.72;102% of Medicaid interim rate","7.31","75","","","Percent of Total Billed Charges","neg_dollar:$7.31","8.38","86","","","Percent of Total Billed Charges","neg_dollar:$8.38","6.82","70","","","Percent of Total Billed Charges","neg_dollar:$6.82","5.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.55;103.5% of Medicaid interim rate","9.75","150","","","Percent of Total Billed Charges","neg_dollar:$15.07;150% of Medicaid interim rate","7.80","80","","","Percent of Total Billed Charges","neg_dollar:$7.80;Percent of Total Billed Charges","8.97","92","","","Percent of Total Billed Charges","neg_dollar:$8.97","5.07","52","","","Percent of Total Billed Charges","neg_dollar:$5.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","9.75","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","9.00",""
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN","J3480","HCPCS","00338-0705-48","NDC","636","RC","","Facility","Outpatient","1","UN","9.57","9.57","","","","9.57","Fee Schedule","","","","","9.57","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","4.97","52","","","Percent of Total Billed Charges","neg_dollar:$4.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","9.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.23","86","","","Percent of Total Billed Charges","neg_dollar:$8.23","6.69","70","","","Percent of Total Billed Charges","neg_dollar:$6.69","4.97","52","","","Percent of Total Billed Charges","neg_dollar:$4.97;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.62;102% of Medicaid interim rate","7.17","75","","","Percent of Total Billed Charges","neg_dollar:$7.17","8.23","86","","","Percent of Total Billed Charges","neg_dollar:$8.23","6.69","70","","","Percent of Total Billed Charges","neg_dollar:$6.69","5.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.45;103.5% of Medicaid interim rate","9.57","150","","","Percent of Total Billed Charges","neg_dollar:$14.79;150% of Medicaid interim rate","7.65","80","","","Percent of Total Billed Charges","neg_dollar:$7.65;Percent of Total Billed Charges","8.80","92","","","Percent of Total Billed Charges","neg_dollar:$8.80","4.97","52","","","Percent of Total Billed Charges","neg_dollar:$4.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.97","52","","","Percent of Total Billed Charges","neg_dollar:$4.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","9.00",""
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN","J3480","HCPCS","00338-0705-48","NDC","250","RC","","Facility","Outpatient","1","UN","9.57","9.57","","","","9.57","Fee Schedule","","","","","9.57","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","9.57","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.97","52","","","Percent of Total Billed Charges","neg_dollar:$4.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.97","52","","","Percent of Total Billed Charges","neg_dollar:$4.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.23","86","","","Percent of Total Billed Charges","neg_dollar:$8.23","6.69","70","","","Percent of Total Billed Charges","neg_dollar:$6.69","","52","","9.57","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.62;102% of Medicaid interim rate","7.17","75","","","Percent of Total Billed Charges","neg_dollar:$7.17","8.23","86","","","Percent of Total Billed Charges","neg_dollar:$8.23","6.69","70","","","Percent of Total Billed Charges","neg_dollar:$6.69","5.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.45;103.5% of Medicaid interim rate","9.57","150","","","Percent of Total Billed Charges","neg_dollar:$14.79;150% of Medicaid interim rate","7.65","80","","","Percent of Total Billed Charges","neg_dollar:$7.65;Percent of Total Billed Charges","8.80","92","","","Percent of Total Billed Charges","neg_dollar:$8.80","4.97","52","","","Percent of Total Billed Charges","neg_dollar:$4.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","9.57","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","9.00",""
"KCL (0.149%) IN NACL 20-0.9 MEQ/L-% IV SOLN","J3480","HCPCS","00990-7115-09","NDC","636","RC","","Facility","Outpatient","1","UN","6","6.00","","","","6.00","Fee Schedule","","","","","6.00","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","6.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","6.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.16","86","","","Percent of Total Billed Charges","neg_dollar:$5.16","4.19","70","","","Percent of Total Billed Charges","neg_dollar:$4.19","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","3.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.52;102% of Medicaid interim rate","4.50","75","","","Percent of Total Billed Charges","neg_dollar:$4.50","5.16","86","","","Percent of Total Billed Charges","neg_dollar:$5.16","4.19","70","","","Percent of Total Billed Charges","neg_dollar:$4.19","3.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.42;103.5% of Medicaid interim rate","6.00","150","","","Percent of Total Billed Charges","neg_dollar:$9.27;150% of Medicaid interim rate","4.80","80","","","Percent of Total Billed Charges","neg_dollar:$4.80;Percent of Total Billed Charges","5.52","92","","","Percent of Total Billed Charges","neg_dollar:$5.52","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","6.00",""
"KCL (0.149%) IN NACL 20-0.9 MEQ/L-% IV SOLN","J3480","HCPCS","00990-7115-09","NDC","250","RC","","Facility","Outpatient","1","UN","6","6.00","","","","6.00","Fee Schedule","","","","","6.00","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","6.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.16","86","","","Percent of Total Billed Charges","neg_dollar:$5.16","4.19","70","","","Percent of Total Billed Charges","neg_dollar:$4.19","","52","","6.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.52;102% of Medicaid interim rate","4.50","75","","","Percent of Total Billed Charges","neg_dollar:$4.50","5.16","86","","","Percent of Total Billed Charges","neg_dollar:$5.16","4.19","70","","","Percent of Total Billed Charges","neg_dollar:$4.19","3.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.42;103.5% of Medicaid interim rate","6.00","150","","","Percent of Total Billed Charges","neg_dollar:$9.27;150% of Medicaid interim rate","4.80","80","","","Percent of Total Billed Charges","neg_dollar:$4.80;Percent of Total Billed Charges","5.52","92","","","Percent of Total Billed Charges","neg_dollar:$5.52","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","6.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","6.00",""
"ZOLEDRONIC ACID 5 MG/100ML IV SOLN","J3489","HCPCS","55111-688-52","NDC","636","RC","","Facility","Outpatient","1","UN","137.50","137.50","","","","137.50","Fee Schedule","","","","","137.50","Fee Schedule","101% of Medicare Fee Schedule","","","","137.50","Fee Schedule","","71.50","52","","","Percent of Total Billed Charges","neg_dollar:$71.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","137.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","137.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","118.25","86","","","Percent of Total Billed Charges","neg_dollar:$118.25","96.25","70","","","Percent of Total Billed Charges","neg_dollar:$96.25","71.50","52","","","Percent of Total Billed Charges","neg_dollar:$71.50;105% Medicare Outpatient Cost to Charge Ratio of 52%","80.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$80.78;102% of Medicaid interim rate","103.12","75","","","Percent of Total Billed Charges","neg_dollar:$103.12","118.25","86","","","Percent of Total Billed Charges","neg_dollar:$118.25","96.25","70","","","Percent of Total Billed Charges","neg_dollar:$96.25","78.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$78.37;103.5% of Medicaid interim rate","137.50","150","","","Percent of Total Billed Charges","neg_dollar:$212.58;150% of Medicaid interim rate","110.00","80","","","Percent of Total Billed Charges","neg_dollar:$110;Percent of Total Billed Charges","126.50","92","","","Percent of Total Billed Charges","neg_dollar:$126.50","71.50","52","","","Percent of Total Billed Charges","neg_dollar:$71.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","71.50","52","","","Percent of Total Billed Charges","neg_dollar:$71.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","71.00","137.00",""
"FAMOTIDINE (PF) 20 MG/2ML IV SOLN","J3490","HCPCS","67457-433-00","NDC","636","RC","","Facility","Outpatient","1","UN","89.30","89.30","","","","89.30","Fee Schedule","","","","","89.30","Fee Schedule","101% of Medicare Fee Schedule","","","","89.30","Fee Schedule","","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.79","86","","","Percent of Total Billed Charges","neg_dollar:$76.79","62.50","70","","","Percent of Total Billed Charges","neg_dollar:$62.50","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.46;102% of Medicaid interim rate","66.97","75","","","Percent of Total Billed Charges","neg_dollar:$66.97","76.79","86","","","Percent of Total Billed Charges","neg_dollar:$76.79","62.50","70","","","Percent of Total Billed Charges","neg_dollar:$62.50","50.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.90;103.5% of Medicaid interim rate","89.30","150","","","Percent of Total Billed Charges","neg_dollar:$138.06;150% of Medicaid interim rate","71.44","80","","","Percent of Total Billed Charges","neg_dollar:$71.44;Percent of Total Billed Charges","82.15","92","","","Percent of Total Billed Charges","neg_dollar:$82.15","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.00","89.00",""
"LACTATED RINGERS IV BOLUS","J7120","HCPCS","00409-7953-09","NDC","250","RC","","Facility","Outpatient","1","UN","52.50","52.50","","","","2.00","Fee Schedule","","","","","26.00","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","52.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","27.30","52","","","Percent of Total Billed Charges","neg_dollar:$27.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.30","52","","","Percent of Total Billed Charges","neg_dollar:$27.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.15","86","","","Percent of Total Billed Charges","neg_dollar:$45.15","36.75","70","","","Percent of Total Billed Charges","neg_dollar:$36.75","","52","","48.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","30.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.84;102% of Medicaid interim rate","39.37","75","","","Percent of Total Billed Charges","neg_dollar:$39.37","45.15","86","","","Percent of Total Billed Charges","neg_dollar:$45.15","36.75","70","","","Percent of Total Billed Charges","neg_dollar:$36.75","29.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.92;103.5% of Medicaid interim rate","52.50","150","","","Percent of Total Billed Charges","neg_dollar:$81.16;150% of Medicaid interim rate","42.00","80","","","Percent of Total Billed Charges","neg_dollar:$42;Percent of Total Billed Charges","48.30","92","","","Percent of Total Billed Charges","neg_dollar:$48.30","27.30","52","","","Percent of Total Billed Charges","neg_dollar:$27.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","36.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","52.00",""
"LACTATED RINGERS IV BOLUS","J7120","HCPCS","00990-7953-09","NDC","250","RC","","Facility","Outpatient","1","UN","59.45","59.45","","","","2.00","Fee Schedule","","","","","26.00","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","59.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","30.91","52","","","Percent of Total Billed Charges","neg_dollar:$30.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.91","52","","","Percent of Total Billed Charges","neg_dollar:$30.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.13","86","","","Percent of Total Billed Charges","neg_dollar:$51.13","41.61","70","","","Percent of Total Billed Charges","neg_dollar:$41.61","","52","","48.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","34.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.92;102% of Medicaid interim rate","44.59","75","","","Percent of Total Billed Charges","neg_dollar:$44.59","51.13","86","","","Percent of Total Billed Charges","neg_dollar:$51.13","41.61","70","","","Percent of Total Billed Charges","neg_dollar:$41.61","33.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.88;103.5% of Medicaid interim rate","59.45","150","","","Percent of Total Billed Charges","neg_dollar:$91.91;150% of Medicaid interim rate","47.56","80","","","Percent of Total Billed Charges","neg_dollar:$47.56;Percent of Total Billed Charges","54.69","92","","","Percent of Total Billed Charges","neg_dollar:$54.69","30.91","52","","","Percent of Total Billed Charges","neg_dollar:$30.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","36.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","59.00",""
"LACTATED RINGERS IV SOLN","J7120","HCPCS","00990-7953-09","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","2.00","Fee Schedule","","","","","26.00","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","48.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","36.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","60.00",""
"LACTATED RINGERS IV SOLN","J7120","HCPCS","00409-7953-09","NDC","636","RC","","Facility","Outpatient","1","UN","60","60.00","","","","2.00","Fee Schedule","","","","","26.00","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","60.00",""
"LACTATED RINGERS IV SOLN","J7120","HCPCS","00990-7953-09","NDC","636","RC","","Facility","Outpatient","1","UN","60","60.00","","","","2.00","Fee Schedule","","","","","26.00","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","60.00",""
"LACTATED RINGERS IV SOLN","J7120","HCPCS","00409-7953-09","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","2.00","Fee Schedule","","","","","26.00","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","48.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","36.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","60.00",""
"PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT","J7168","HCPCS","63833-386-02","NDC","636","RC","","Facility","Outpatient","1","UN","6","6.00","","","","6.00","Fee Schedule","","","","","6.00","Fee Schedule","101% of Medicare Fee Schedule","","","","6.00","Fee Schedule","","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","6.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","6.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.16","86","","","Percent of Total Billed Charges","neg_dollar:$5.16","4.20","70","","","Percent of Total Billed Charges","neg_dollar:$4.20","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","3.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.52;102% of Medicaid interim rate","4.50","75","","","Percent of Total Billed Charges","neg_dollar:$4.50","5.16","86","","","Percent of Total Billed Charges","neg_dollar:$5.16","4.20","70","","","Percent of Total Billed Charges","neg_dollar:$4.20","3.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.42;103.5% of Medicaid interim rate","6.00","150","","","Percent of Total Billed Charges","neg_dollar:$9.28;150% of Medicaid interim rate","4.80","80","","","Percent of Total Billed Charges","neg_dollar:$4.80;Percent of Total Billed Charges","5.52","92","","","Percent of Total Billed Charges","neg_dollar:$5.52","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.12","52","","","Percent of Total Billed Charges","neg_dollar:$3.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","6.00",""
"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN","J7510","HCPCS","00121-0759-08","NDC","636","RC","","Facility","Outpatient","1","EA","0.66","0.66","","","","0.66","Fee Schedule","","","","","0.66","Fee Schedule","101% of Medicare Fee Schedule","","","","0.66","Fee Schedule","","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","86","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.46","70","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% of Medicaid interim rate","0.49","75","","","Percent of Total Billed Charges","neg_dollar:$0.49","0.57","86","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.46","70","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.37;103.5% of Medicaid interim rate","0.66","150","","","Percent of Total Billed Charges","neg_dollar:$1.03;150% of Medicaid interim rate","0.53","80","","","Percent of Total Billed Charges","neg_dollar:$0.53;Percent of Total Billed Charges","0.61","92","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PREDNISONE 1 MG PO TABS","J7512","HCPCS","59746-171-06","NDC","250","RC","","Facility","Outpatient","1","ME","0.93","0.93","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","","","0.93","Fee Schedule","","","52","","0.93","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","","52","","0.93","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.70","75","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.80","86","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;103.5% of Medicaid interim rate","0.93","150","","","Percent of Total Billed Charges","neg_dollar:$1.44;150% of Medicaid interim rate","0.75","80","","","Percent of Total Billed Charges","neg_dollar:$0.75;Percent of Total Billed Charges","0.86","92","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.93","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PREDNISONE 10 MG PO TABS","J7512","HCPCS","00904-6923-61","NDC","636","RC","","Facility","Outpatient","10","ME","0.12","0.12","","","","0.12","Fee Schedule","","","","","0.12","Fee Schedule","101% of Medicare Fee Schedule","","","","0.12","Fee Schedule","","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.10","86","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.08","70","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.07;102% of Medicaid interim rate","0.09","75","","","Percent of Total Billed Charges","neg_dollar:$0.09","0.10","86","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.08","70","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.06;103.5% of Medicaid interim rate","0.12","150","","","Percent of Total Billed Charges","neg_dollar:$0.18;150% of Medicaid interim rate","0.09","80","","","Percent of Total Billed Charges","neg_dollar:$0.09;Percent of Total Billed Charges","0.11","92","","","Percent of Total Billed Charges","neg_dollar:$0.11","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PREDNISONE 10 MG PO TABS","J7512","HCPCS","00904-6923-61","NDC","250","RC","","Facility","Outpatient","10","ME","0.09","0.09","","","","0.09","Fee Schedule","","","","","0.09","Fee Schedule","","","","","0.09","Fee Schedule","","","52","","0.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.08","86","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.06","70","","","Percent of Total Billed Charges","neg_dollar:$0.06","","52","","0.09","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.05;102% of Medicaid interim rate","0.07","75","","","Percent of Total Billed Charges","neg_dollar:$0.07","0.08","86","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.06","70","","","Percent of Total Billed Charges","neg_dollar:$0.06","0.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.05;103.5% of Medicaid interim rate","0.09","150","","","Percent of Total Billed Charges","neg_dollar:$0.15;150% of Medicaid interim rate","0.07","80","","","Percent of Total Billed Charges","neg_dollar:$0.07;Percent of Total Billed Charges","0.09","92","","","Percent of Total Billed Charges","neg_dollar:$0.09","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.09","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PREDNISONE 20 MG PO TABS","J7512","HCPCS","60687-145-11","NDC","636","RC","","Facility","Outpatient","20","ME","0.04","0.04","","","","0.04","Fee Schedule","","","","","0.04","Fee Schedule","101% of Medicare Fee Schedule","","","","0.04","Fee Schedule","","0.02","52","","","Percent of Total Billed Charges","neg_dollar:$0.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.03","86","","","Percent of Total Billed Charges","neg_dollar:$0.03","0.02","70","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.02","52","","","Percent of Total Billed Charges","neg_dollar:$0.02;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.02;102% of Medicaid interim rate","0.03","75","","","Percent of Total Billed Charges","neg_dollar:$0.03","0.03","86","","","Percent of Total Billed Charges","neg_dollar:$0.03","0.02","70","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.02;103.5% of Medicaid interim rate","0.04","150","","","Percent of Total Billed Charges","neg_dollar:$0.06;150% of Medicaid interim rate","0.03","80","","","Percent of Total Billed Charges","neg_dollar:$0.03;Percent of Total Billed Charges","0.03","92","","","Percent of Total Billed Charges","neg_dollar:$0.03","0.02","52","","","Percent of Total Billed Charges","neg_dollar:$0.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.02","52","","","Percent of Total Billed Charges","neg_dollar:$0.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PREDNISONE 20 MG PO TABS","J7512","HCPCS","60687-145-11","NDC","250","RC","","Facility","Outpatient","20","ME","0.03","0.03","","","","0.03","Fee Schedule","","","","","0.03","Fee Schedule","","","","","0.03","Fee Schedule","","","52","","0.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.03","86","","","Percent of Total Billed Charges","neg_dollar:$0.03","0.02","70","","","Percent of Total Billed Charges","neg_dollar:$0.02","","52","","0.03","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.02;102% of Medicaid interim rate","0.02","75","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.03","86","","","Percent of Total Billed Charges","neg_dollar:$0.03","0.02","70","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.02;103.5% of Medicaid interim rate","0.03","150","","","Percent of Total Billed Charges","neg_dollar:$0.05;150% of Medicaid interim rate","0.03","80","","","Percent of Total Billed Charges","neg_dollar:$0.03;Percent of Total Billed Charges","0.03","92","","","Percent of Total Billed Charges","neg_dollar:$0.03","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.03","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PREDNISONE 20 MG PO TABS","J7512","HCPCS","60687-145-01","NDC","636","RC","","Facility","Outpatient","20","ME","0.03","0.03","","","","0.03","Fee Schedule","","","","","0.03","Fee Schedule","101% of Medicare Fee Schedule","","","","0.03","Fee Schedule","","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.03","86","","","Percent of Total Billed Charges","neg_dollar:$0.03","0.02","70","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.02;102% of Medicaid interim rate","0.02","75","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.03","86","","","Percent of Total Billed Charges","neg_dollar:$0.03","0.02","70","","","Percent of Total Billed Charges","neg_dollar:$0.02","0.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.02;103.5% of Medicaid interim rate","0.03","150","","","Percent of Total Billed Charges","neg_dollar:$0.05;150% of Medicaid interim rate","0.03","80","","","Percent of Total Billed Charges","neg_dollar:$0.03;Percent of Total Billed Charges","0.03","92","","","Percent of Total Billed Charges","neg_dollar:$0.03","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.01","52","","","Percent of Total Billed Charges","neg_dollar:$0.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PREDNISONE 5 MG PO TABS","J7512","HCPCS","60687-122-11","NDC","636","RC","","Facility","Outpatient","1","ME","0.25","0.25","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","101% of Medicare Fee Schedule","","","","0.25","Fee Schedule","","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% of Medicaid interim rate","0.18","75","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.25","150","","","Percent of Total Billed Charges","neg_dollar:$0.38;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PREDNISONE 5 MG PO TABS","J7512","HCPCS","60687-122-11","NDC","250","RC","","Facility","Outpatient","5","ME","0.26","0.26","","","","0.26","Fee Schedule","","","","","0.26","Fee Schedule","","","","","0.26","Fee Schedule","","","52","","0.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.22","86","","","Percent of Total Billed Charges","neg_dollar:$0.22","0.18","70","","","Percent of Total Billed Charges","neg_dollar:$0.18","","52","","0.26","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.15;102% of Medicaid interim rate","0.19","75","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.22","86","","","Percent of Total Billed Charges","neg_dollar:$0.22","0.18","70","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.26","150","","","Percent of Total Billed Charges","neg_dollar:$0.40;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.24","92","","","Percent of Total Billed Charges","neg_dollar:$0.24","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.26","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MYCOPHENOLATE MOFETIL 250 MG PO CAPS","J7517","HCPCS","00004-0259-01","NDC","636","RC","","Facility","Outpatient","250","ME","11.80","11.80","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","6.13","52","","","Percent of Total Billed Charges","neg_dollar:$6.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.14","86","","","Percent of Total Billed Charges","neg_dollar:$10.14","8.26","70","","","Percent of Total Billed Charges","neg_dollar:$8.26","6.13","52","","","Percent of Total Billed Charges","neg_dollar:$6.13;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.93;102% of Medicaid interim rate","8.85","75","","","Percent of Total Billed Charges","neg_dollar:$8.85","10.14","86","","","Percent of Total Billed Charges","neg_dollar:$10.14","8.26","70","","","Percent of Total Billed Charges","neg_dollar:$8.26","6.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.72;103.5% of Medicaid interim rate","11.80","150","","","Percent of Total Billed Charges","neg_dollar:$18.24;150% of Medicaid interim rate","9.44","80","","","Percent of Total Billed Charges","neg_dollar:$9.44;Percent of Total Billed Charges","10.85","92","","","Percent of Total Billed Charges","neg_dollar:$10.85","6.13","52","","","Percent of Total Billed Charges","neg_dollar:$6.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.13","52","","","Percent of Total Billed Charges","neg_dollar:$6.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","11.00",""
"MYCOPHENOLATE MOFETIL 500 MG PO TABS","J7517","HCPCS","60687-438-11","NDC","250","RC","","Facility","Outpatient","500","ME","0.95","0.95","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","86","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.67","70","","","Percent of Total Billed Charges","neg_dollar:$0.67","","52","","0.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% of Medicaid interim rate","0.71","75","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.82","86","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.67","70","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;103.5% of Medicaid interim rate","0.95","150","","","Percent of Total Billed Charges","neg_dollar:$1.48;150% of Medicaid interim rate","0.76","80","","","Percent of Total Billed Charges","neg_dollar:$0.76;Percent of Total Billed Charges","0.88","92","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.95","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MYCOPHENOLATE MOFETIL 500 MG PO TABS","J7517","HCPCS","60687-438-01","NDC","250","RC","","Facility","Outpatient","500","ME","0.91","0.91","","","","0.91","Fee Schedule","","","","","0.91","Fee Schedule","","","","","0.91","Fee Schedule","","","52","","0.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","","52","","0.91","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% of Medicaid interim rate","0.68","75","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.78","86","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;103.5% of Medicaid interim rate","0.91","150","","","Percent of Total Billed Charges","neg_dollar:$1.41;150% of Medicaid interim rate","0.73","80","","","Percent of Total Billed Charges","neg_dollar:$0.73;Percent of Total Billed Charges","0.83","92","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.47","52","","","Percent of Total Billed Charges","neg_dollar:$0.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.91","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MYCOPHENOLATE MOFETIL 500 MG PO TABS","J7517","HCPCS","60687-438-11","NDC","636","RC","","Facility","Outpatient","500","ME","1","1.00","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% of Medicaid interim rate","0.75","75","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.00","150","","","Percent of Total Billed Charges","neg_dollar:$1.54;150% of Medicaid interim rate","0.80","80","","","Percent of Total Billed Charges","neg_dollar:$0.80;Percent of Total Billed Charges","0.92","92","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU","J7614","HCPCS","76204-900-11","NDC","250","RC","","Facility","Outpatient","1","UN","1.33","1.33","","","","1.33","Fee Schedule","","","","","1.33","Fee Schedule","","","","","1.33","Fee Schedule","","","52","","1.33","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","86","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.93","70","","","Percent of Total Billed Charges","neg_dollar:$0.93","","52","","1.33","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% of Medicaid interim rate","0.99","75","","","Percent of Total Billed Charges","neg_dollar:$0.99","1.14","86","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.93","70","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.75;103.5% of Medicaid interim rate","1.33","150","","","Percent of Total Billed Charges","neg_dollar:$2.06;150% of Medicaid interim rate","1.06","80","","","Percent of Total Billed Charges","neg_dollar:$1.06;Percent of Total Billed Charges","1.22","92","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.33","Fee Schedule","","1.00","1.00",""
"BUDESONIDE 0.5 MG/2ML IN SUSP","J7626","HCPCS","60687-524-79","NDC","250","RC","","Facility","Outpatient","1","UN","12.25","12.25","","","","4.00","Fee Schedule","","","","","6.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","12.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.37","52","","","Percent of Total Billed Charges","neg_dollar:$6.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.37","52","","","Percent of Total Billed Charges","neg_dollar:$6.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.53","86","","","Percent of Total Billed Charges","neg_dollar:$10.53","8.57","70","","","Percent of Total Billed Charges","neg_dollar:$8.57","","52","","10.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.19;102% of Medicaid interim rate","9.18","75","","","Percent of Total Billed Charges","neg_dollar:$9.18","10.53","86","","","Percent of Total Billed Charges","neg_dollar:$10.53","8.57","70","","","Percent of Total Billed Charges","neg_dollar:$8.57","6.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.98;103.5% of Medicaid interim rate","12.25","150","","","Percent of Total Billed Charges","neg_dollar:$18.93;150% of Medicaid interim rate","9.80","80","","","Percent of Total Billed Charges","neg_dollar:$9.80;Percent of Total Billed Charges","11.27","92","","","Percent of Total Billed Charges","neg_dollar:$11.27","6.37","52","","","Percent of Total Billed Charges","neg_dollar:$6.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","7.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","12.00",""
"BUDESONIDE 0.5 MG/2ML IN SUSP","J7626","HCPCS","60687-524-83","NDC","250","RC","","Facility","Outpatient","1","UN","12.25","12.25","","","","4.00","Fee Schedule","","","","","6.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","12.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.37","52","","","Percent of Total Billed Charges","neg_dollar:$6.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.37","52","","","Percent of Total Billed Charges","neg_dollar:$6.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.53","86","","","Percent of Total Billed Charges","neg_dollar:$10.53","8.57","70","","","Percent of Total Billed Charges","neg_dollar:$8.57","","52","","10.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.19;102% of Medicaid interim rate","9.18","75","","","Percent of Total Billed Charges","neg_dollar:$9.18","10.53","86","","","Percent of Total Billed Charges","neg_dollar:$10.53","8.57","70","","","Percent of Total Billed Charges","neg_dollar:$8.57","6.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.98;103.5% of Medicaid interim rate","12.25","150","","","Percent of Total Billed Charges","neg_dollar:$18.93;150% of Medicaid interim rate","9.80","80","","","Percent of Total Billed Charges","neg_dollar:$9.80;Percent of Total Billed Charges","11.27","92","","","Percent of Total Billed Charges","neg_dollar:$11.27","6.37","52","","","Percent of Total Billed Charges","neg_dollar:$6.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","7.00","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","12.00",""
"IPRATROPIUM BROMIDE 0.02 % IN SOLN","J7644","HCPCS","00487-9801-01","NDC","250","RC","","Facility","Outpatient","1","UN","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"DEXAMETHASONE 4 MG PO TABS","J8540","HCPCS","60687-718-11","NDC","636","RC","","Facility","Outpatient","4","ME","0.10","0.10","","","","0.10","Fee Schedule","","","","","0.10","Fee Schedule","101% of Medicare Fee Schedule","","","","0.10","Fee Schedule","","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.08","86","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.07","70","","","Percent of Total Billed Charges","neg_dollar:$0.07","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.06;102% of Medicaid interim rate","0.07","75","","","Percent of Total Billed Charges","neg_dollar:$0.07","0.08","86","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.07","70","","","Percent of Total Billed Charges","neg_dollar:$0.07","0.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.05;103.5% of Medicaid interim rate","0.10","150","","","Percent of Total Billed Charges","neg_dollar:$0.16;150% of Medicaid interim rate","0.08","80","","","Percent of Total Billed Charges","neg_dollar:$0.08;Percent of Total Billed Charges","0.09","92","","","Percent of Total Billed Charges","neg_dollar:$0.09","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.05","52","","","Percent of Total Billed Charges","neg_dollar:$0.05;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ALBUMIN HUMAN-KJDA 25 % IV SOLN","P9046","HCPCS","64208-2512-7","NDC","250","RC","","Facility","Outpatient","1","UN","73.45","73.45","","","","73.45","Fee Schedule","","","","","73.45","Fee Schedule","","","","","73.45","Fee Schedule","","","52","","73.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","38.19","52","","","Percent of Total Billed Charges","neg_dollar:$38.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","38.19","52","","","Percent of Total Billed Charges","neg_dollar:$38.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","63.17","86","","","Percent of Total Billed Charges","neg_dollar:$63.17","51.41","70","","","Percent of Total Billed Charges","neg_dollar:$51.41","","52","","73.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","43.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$43.15;102% of Medicaid interim rate","55.09","75","","","Percent of Total Billed Charges","neg_dollar:$55.09","63.17","86","","","Percent of Total Billed Charges","neg_dollar:$63.17","51.41","70","","","Percent of Total Billed Charges","neg_dollar:$51.41","41.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$41.86;103.5% of Medicaid interim rate","73.45","150","","","Percent of Total Billed Charges","neg_dollar:$113.56;150% of Medicaid interim rate","58.76","80","","","Percent of Total Billed Charges","neg_dollar:$58.76;Percent of Total Billed Charges","67.57","92","","","Percent of Total Billed Charges","neg_dollar:$67.57","38.19","52","","","Percent of Total Billed Charges","neg_dollar:$38.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","73.45","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","38.00","73.00",""
"ALBUMIN HUMAN-KJDA 25 % IV SOLN","P9046","HCPCS","64208-2512-7","NDC","636","RC","","Facility","Outpatient","1","UN","65.50","65.50","","","","65.50","Fee Schedule","","","","","65.50","Fee Schedule","101% of Medicare Fee Schedule","","","","65.50","Fee Schedule","","34.06","52","","","Percent of Total Billed Charges","neg_dollar:$34.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","65.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","65.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","56.33","86","","","Percent of Total Billed Charges","neg_dollar:$56.33","45.85","70","","","Percent of Total Billed Charges","neg_dollar:$45.85","34.06","52","","","Percent of Total Billed Charges","neg_dollar:$34.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","38.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$38.48;102% of Medicaid interim rate","49.12","75","","","Percent of Total Billed Charges","neg_dollar:$49.12","56.33","86","","","Percent of Total Billed Charges","neg_dollar:$56.33","45.85","70","","","Percent of Total Billed Charges","neg_dollar:$45.85","37.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.33;103.5% of Medicaid interim rate","65.50","150","","","Percent of Total Billed Charges","neg_dollar:$101.27;150% of Medicaid interim rate","52.40","80","","","Percent of Total Billed Charges","neg_dollar:$52.40;Percent of Total Billed Charges","60.26","92","","","Percent of Total Billed Charges","neg_dollar:$60.26","34.06","52","","","Percent of Total Billed Charges","neg_dollar:$34.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","34.06","52","","","Percent of Total Billed Charges","neg_dollar:$34.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","34.00","65.00",""
"FERUMOXYTOL 510 MG/17ML IV SOLN","Q0138","HCPCS","00781-3154-01","NDC","250","RC","","Facility","Outpatient","1","UN","3.06","3.06","","","","3.06","Fee Schedule","","","","","3.06","Fee Schedule","","","","","3.06","Fee Schedule","","","52","","3.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","52","","","Percent of Total Billed Charges","neg_dollar:$1.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","52","","","Percent of Total Billed Charges","neg_dollar:$1.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.63","86","","","Percent of Total Billed Charges","neg_dollar:$2.63","2.14","70","","","Percent of Total Billed Charges","neg_dollar:$2.14","","52","","3.06","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.80;102% of Medicaid interim rate","2.30","75","","","Percent of Total Billed Charges","neg_dollar:$2.30","2.63","86","","","Percent of Total Billed Charges","neg_dollar:$2.63","2.14","70","","","Percent of Total Billed Charges","neg_dollar:$2.14","1.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.74;103.5% of Medicaid interim rate","3.06","150","","","Percent of Total Billed Charges","neg_dollar:$4.74;150% of Medicaid interim rate","2.45","80","","","Percent of Total Billed Charges","neg_dollar:$2.45;Percent of Total Billed Charges","2.82","92","","","Percent of Total Billed Charges","neg_dollar:$2.82","1.59","52","","","Percent of Total Billed Charges","neg_dollar:$1.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.06","Fee Schedule","","1.00","3.00",""
"FERUMOXYTOL 510 MG/17ML IV SOLN","Q0138","HCPCS","00781-3154-01","NDC","636","RC","","Facility","Outpatient","1","UN","3.08","3.08","","","","3.08","Fee Schedule","","","","","3.08","Fee Schedule","101% of Medicare Fee Schedule","","","","3.08","Fee Schedule","","1.60","52","","","Percent of Total Billed Charges","neg_dollar:$1.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.65","86","","","Percent of Total Billed Charges","neg_dollar:$2.65","2.16","70","","","Percent of Total Billed Charges","neg_dollar:$2.16","1.60","52","","","Percent of Total Billed Charges","neg_dollar:$1.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.81;102% of Medicaid interim rate","2.31","75","","","Percent of Total Billed Charges","neg_dollar:$2.31","2.65","86","","","Percent of Total Billed Charges","neg_dollar:$2.65","2.16","70","","","Percent of Total Billed Charges","neg_dollar:$2.16","1.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.75;103.5% of Medicaid interim rate","3.08","150","","","Percent of Total Billed Charges","neg_dollar:$4.77;150% of Medicaid interim rate","2.47","80","","","Percent of Total Billed Charges","neg_dollar:$2.47;Percent of Total Billed Charges","2.84","92","","","Percent of Total Billed Charges","neg_dollar:$2.84","1.60","52","","","Percent of Total Billed Charges","neg_dollar:$1.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.60","52","","","Percent of Total Billed Charges","neg_dollar:$1.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"AZITHROMYCIN 200 MG/5ML PO SUSR","Q0144","HCPCS","00093-2026-31","NDC","250","RC","","Facility","Outpatient","1","UN","19.65","19.65","","","","19.65","Fee Schedule","","","","","19.65","Fee Schedule","","","","","19.65","Fee Schedule","","","52","","19.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.21","52","","","Percent of Total Billed Charges","neg_dollar:$10.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.21","52","","","Percent of Total Billed Charges","neg_dollar:$10.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.89","86","","","Percent of Total Billed Charges","neg_dollar:$16.89","13.75","70","","","Percent of Total Billed Charges","neg_dollar:$13.75","","52","","19.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","11.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.54;102% of Medicaid interim rate","14.73","75","","","Percent of Total Billed Charges","neg_dollar:$14.73","16.89","86","","","Percent of Total Billed Charges","neg_dollar:$16.89","13.75","70","","","Percent of Total Billed Charges","neg_dollar:$13.75","11.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.20;103.5% of Medicaid interim rate","19.65","150","","","Percent of Total Billed Charges","neg_dollar:$30.37;150% of Medicaid interim rate","15.71","80","","","Percent of Total Billed Charges","neg_dollar:$15.71;Percent of Total Billed Charges","18.07","92","","","Percent of Total Billed Charges","neg_dollar:$18.07","10.21","52","","","Percent of Total Billed Charges","neg_dollar:$10.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","19.65","Fee Schedule","","10.00","19.00",""
"AZITHROMYCIN 250 MG PO TABS","Q0144","HCPCS","00904-7350-06","NDC","250","RC","","Facility","Outpatient","250","ME","4.16","4.16","","","","4.16","Fee Schedule","","","","","4.16","Fee Schedule","","","","","4.16","Fee Schedule","","","52","","4.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.16","52","","","Percent of Total Billed Charges","neg_dollar:$2.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.16","52","","","Percent of Total Billed Charges","neg_dollar:$2.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.57","86","","","Percent of Total Billed Charges","neg_dollar:$3.57","2.91","70","","","Percent of Total Billed Charges","neg_dollar:$2.91","","52","","4.16","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.44;102% of Medicaid interim rate","3.12","75","","","Percent of Total Billed Charges","neg_dollar:$3.12","3.57","86","","","Percent of Total Billed Charges","neg_dollar:$3.57","2.91","70","","","Percent of Total Billed Charges","neg_dollar:$2.91","2.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.37;103.5% of Medicaid interim rate","4.16","150","","","Percent of Total Billed Charges","neg_dollar:$6.43;150% of Medicaid interim rate","3.32","80","","","Percent of Total Billed Charges","neg_dollar:$3.32;Percent of Total Billed Charges","3.82","92","","","Percent of Total Billed Charges","neg_dollar:$3.82","2.16","52","","","Percent of Total Billed Charges","neg_dollar:$2.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.16","Fee Schedule","","2.00","4.00",""
"AZITHROMYCIN 250 MG PO TABS","Q0144","HCPCS","60687-742-65","NDC","250","RC","","Facility","Outpatient","250","ME","4.75","4.75","","","","4.75","Fee Schedule","","","","","4.75","Fee Schedule","","","","","4.75","Fee Schedule","","","52","","4.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.47","52","","","Percent of Total Billed Charges","neg_dollar:$2.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.47","52","","","Percent of Total Billed Charges","neg_dollar:$2.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.08","86","","","Percent of Total Billed Charges","neg_dollar:$4.08","3.32","70","","","Percent of Total Billed Charges","neg_dollar:$3.32","","52","","4.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.79;102% of Medicaid interim rate","3.56","75","","","Percent of Total Billed Charges","neg_dollar:$3.56","4.08","86","","","Percent of Total Billed Charges","neg_dollar:$4.08","3.32","70","","","Percent of Total Billed Charges","neg_dollar:$3.32","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;103.5% of Medicaid interim rate","4.75","150","","","Percent of Total Billed Charges","neg_dollar:$7.34;150% of Medicaid interim rate","3.80","80","","","Percent of Total Billed Charges","neg_dollar:$3.80;Percent of Total Billed Charges","4.37","92","","","Percent of Total Billed Charges","neg_dollar:$4.37","2.47","52","","","Percent of Total Billed Charges","neg_dollar:$2.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.75","Fee Schedule","","2.00","4.00",""
"AZITHROMYCIN 250 MG PO TABS","Q0144","HCPCS","60687-742-01","NDC","250","RC","","Facility","Outpatient","250","ME","4.81","4.81","","","","4.81","Fee Schedule","","","","","4.81","Fee Schedule","","","","","4.81","Fee Schedule","","","52","","4.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.50","52","","","Percent of Total Billed Charges","neg_dollar:$2.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.50","52","","","Percent of Total Billed Charges","neg_dollar:$2.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.13","86","","","Percent of Total Billed Charges","neg_dollar:$4.13","3.36","70","","","Percent of Total Billed Charges","neg_dollar:$3.36","","52","","4.81","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.82;102% of Medicaid interim rate","3.60","75","","","Percent of Total Billed Charges","neg_dollar:$3.60","4.13","86","","","Percent of Total Billed Charges","neg_dollar:$4.13","3.36","70","","","Percent of Total Billed Charges","neg_dollar:$3.36","2.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.74;103.5% of Medicaid interim rate","4.81","150","","","Percent of Total Billed Charges","neg_dollar:$7.44;150% of Medicaid interim rate","3.85","80","","","Percent of Total Billed Charges","neg_dollar:$3.85;Percent of Total Billed Charges","4.42","92","","","Percent of Total Billed Charges","neg_dollar:$4.42","2.50","52","","","Percent of Total Billed Charges","neg_dollar:$2.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.81","Fee Schedule","","2.00","4.00",""
"AZITHROMYCIN 250 MG PO TABS","Q0144","HCPCS","00904-7350-06","NDC","637","RC","","Facility","Outpatient","250","ME","4","4.00","","","","4.00","Fee Schedule","","","","","4.00","Fee Schedule","101% of Medicare Fee Schedule","","","","4.00","Fee Schedule","","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.44","86","","","Percent of Total Billed Charges","neg_dollar:$3.44","2.80","70","","","Percent of Total Billed Charges","neg_dollar:$2.80","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.34;102% of Medicaid interim rate","3.00","75","","","Percent of Total Billed Charges","neg_dollar:$3","3.44","86","","","Percent of Total Billed Charges","neg_dollar:$3.44","2.80","70","","","Percent of Total Billed Charges","neg_dollar:$2.80","2.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.28;103.5% of Medicaid interim rate","4.00","150","","","Percent of Total Billed Charges","neg_dollar:$6.18;150% of Medicaid interim rate","3.20","80","","","Percent of Total Billed Charges","neg_dollar:$3.20;Percent of Total Billed Charges","3.68","92","","","Percent of Total Billed Charges","neg_dollar:$3.68","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"TELEHEALTH FACILITY FEE","Q3014","HCPCS","90000693","CDM","780","RC","","Facility","Outpatient","","","79","63.20","79.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","79.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","67.94","86","","","Percent of Total Billed Charges","neg_dollar:$67.94","55.30","70","","","Percent of Total Billed Charges","neg_dollar:$55.30","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","46.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$46.41;102% of Medicaid interim rate","59.25","75","","","Percent of Total Billed Charges","neg_dollar:$59.25","67.94","86","","","Percent of Total Billed Charges","neg_dollar:$67.94","55.30","70","","","Percent of Total Billed Charges","neg_dollar:$55.30","45.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$45.02;103.5% of Medicaid interim rate","79.00","150","","","Percent of Total Billed Charges","neg_dollar:$122.13;150% of Medicaid interim rate","63.20","80","","","Percent of Total Billed Charges","neg_dollar:$63.20;Percent of Total Billed Charges","72.68","92","","","Percent of Total Billed Charges","neg_dollar:$72.68","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","41.08","52","","","Percent of Total Billed Charges","neg_dollar:$41.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","41.00","79.00",""
"INTEGRA BMWD PER SQ CM LVL 1","Q4104","HCPCS","27002444","CDM","250","RC","","Facility","Outpatient","","","100","80.00","","","","100.00","Fee Schedule","","","","","100.00","Fee Schedule","","","","","100.00","Fee Schedule","","","52","","100.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;102% Medicare Outpatient Cost to Charge Ratio of 52%","86.00","86","","","Percent of Total Billed Charges","neg_dollar:$86","70.00","70","","","Percent of Total Billed Charges","neg_dollar:$70","","52","","100.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","58.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$58.74;102% of Medicaid interim rate","75.00","75","","","Percent of Total Billed Charges","neg_dollar:$75","86.00","86","","","Percent of Total Billed Charges","neg_dollar:$86","70.00","70","","","Percent of Total Billed Charges","neg_dollar:$70","56.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.99;103.5% of Medicaid interim rate","100.00","150","","","Percent of Total Billed Charges","neg_dollar:$154.60;150% of Medicaid interim rate","80.00","80","","","Percent of Total Billed Charges","neg_dollar:$80;Percent of Total Billed Charges","92.00","92","","","Percent of Total Billed Charges","neg_dollar:$92","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","100.00","Fee Schedule","","52.00","100.00",""
"INTEGRA BMWD PER SQ CM LVL 2","Q4104","HCPCS","27002445","CDM","250","RC","","Facility","Outpatient","","","150","120.00","","","","150.00","Fee Schedule","","","","","150.00","Fee Schedule","","","","","150.00","Fee Schedule","","","52","","150.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;102% Medicare Outpatient Cost to Charge Ratio of 52%","129.00","86","","","Percent of Total Billed Charges","neg_dollar:$129","105.00","70","","","Percent of Total Billed Charges","neg_dollar:$105","","52","","150.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","88.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$88.12;102% of Medicaid interim rate","112.50","75","","","Percent of Total Billed Charges","neg_dollar:$112.50","129.00","86","","","Percent of Total Billed Charges","neg_dollar:$129","105.00","70","","","Percent of Total Billed Charges","neg_dollar:$105","85.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$85.49;103.5% of Medicaid interim rate","150.00","150","","","Percent of Total Billed Charges","neg_dollar:$231.90;150% of Medicaid interim rate","120.00","80","","","Percent of Total Billed Charges","neg_dollar:$120;Percent of Total Billed Charges","138.00","92","","","Percent of Total Billed Charges","neg_dollar:$138","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","150.00","Fee Schedule","","78.00","150.00",""
"INTEGRA BMWD PER SQ CM LVL 3","Q4104","HCPCS","27002446","CDM","250","RC","","Facility","Outpatient","","","200","160.00","","","","200.00","Fee Schedule","","","","","200.00","Fee Schedule","","","","","200.00","Fee Schedule","","","52","","200.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","104.00","52","","","Percent of Total Billed Charges","neg_dollar:$104;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.00","52","","","Percent of Total Billed Charges","neg_dollar:$104;102% Medicare Outpatient Cost to Charge Ratio of 52%","172.00","86","","","Percent of Total Billed Charges","neg_dollar:$172","140.00","70","","","Percent of Total Billed Charges","neg_dollar:$140","","52","","200.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","117.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$117.49;102% of Medicaid interim rate","150.00","75","","","Percent of Total Billed Charges","neg_dollar:$150","172.00","86","","","Percent of Total Billed Charges","neg_dollar:$172","140.00","70","","","Percent of Total Billed Charges","neg_dollar:$140","113.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$113.99;103.5% of Medicaid interim rate","200.00","150","","","Percent of Total Billed Charges","neg_dollar:$309.21;150% of Medicaid interim rate","160.00","80","","","Percent of Total Billed Charges","neg_dollar:$160;Percent of Total Billed Charges","184.00","92","","","Percent of Total Billed Charges","neg_dollar:$184","104.00","52","","","Percent of Total Billed Charges","neg_dollar:$104;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","200.00","Fee Schedule","","104.00","200.00",""
"INTEGRA BMWD PER SQ CM LVL 4","Q4104","HCPCS","27002447","CDM","250","RC","","Facility","Outpatient","","","250","200.00","","","","250.00","Fee Schedule","","","","","250.00","Fee Schedule","","","","","250.00","Fee Schedule","","","52","","250.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","","52","","250.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","146.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$146.87;102% of Medicaid interim rate","187.50","75","","","Percent of Total Billed Charges","neg_dollar:$187.50","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","142.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$142.50;103.5% of Medicaid interim rate","250.00","150","","","Percent of Total Billed Charges","neg_dollar:$386.51;150% of Medicaid interim rate","200.00","80","","","Percent of Total Billed Charges","neg_dollar:$200;Percent of Total Billed Charges","230.00","92","","","Percent of Total Billed Charges","neg_dollar:$230","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","250.00","Fee Schedule","","130.00","250.00",""
"INTEGRA BMWD PER SQ CM LVL 5","Q4104","HCPCS","27002448","CDM","250","RC","","Facility","Outpatient","","","300","240.00","","","","300.00","Fee Schedule","","","","","300.00","Fee Schedule","","","","","300.00","Fee Schedule","","","52","","300.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;102% Medicare Outpatient Cost to Charge Ratio of 52%","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;102% Medicare Outpatient Cost to Charge Ratio of 52%","258.00","86","","","Percent of Total Billed Charges","neg_dollar:$258","210.00","70","","","Percent of Total Billed Charges","neg_dollar:$210","","52","","300.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","176.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$176.24;102% of Medicaid interim rate","225.00","75","","","Percent of Total Billed Charges","neg_dollar:$225","258.00","86","","","Percent of Total Billed Charges","neg_dollar:$258","210.00","70","","","Percent of Total Billed Charges","neg_dollar:$210","170.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$170.99;103.5% of Medicaid interim rate","300.00","150","","","Percent of Total Billed Charges","neg_dollar:$463.81;150% of Medicaid interim rate","240.00","80","","","Percent of Total Billed Charges","neg_dollar:$240;Percent of Total Billed Charges","276.00","92","","","Percent of Total Billed Charges","neg_dollar:$276","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","300.00","Fee Schedule","","156.00","300.00",""
"KERECIS OMEGA3 PER SQ CM LVL 1","Q4158","HCPCS","27005510","CDM","250","RC","","Facility","Outpatient","","","100","80.00","","","","100.00","Fee Schedule","","","","","100.00","Fee Schedule","","","","","100.00","Fee Schedule","","","52","","100.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;102% Medicare Outpatient Cost to Charge Ratio of 52%","86.00","86","","","Percent of Total Billed Charges","neg_dollar:$86","70.00","70","","","Percent of Total Billed Charges","neg_dollar:$70","","52","","100.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","58.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$58.74;102% of Medicaid interim rate","75.00","75","","","Percent of Total Billed Charges","neg_dollar:$75","86.00","86","","","Percent of Total Billed Charges","neg_dollar:$86","70.00","70","","","Percent of Total Billed Charges","neg_dollar:$70","56.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.99;103.5% of Medicaid interim rate","100.00","150","","","Percent of Total Billed Charges","neg_dollar:$154.60;150% of Medicaid interim rate","80.00","80","","","Percent of Total Billed Charges","neg_dollar:$80;Percent of Total Billed Charges","92.00","92","","","Percent of Total Billed Charges","neg_dollar:$92","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","100.00","Fee Schedule","","52.00","100.00",""
"KERECIS OMEGA3 PER SQ CM LVL 2","Q4158","HCPCS","27005511","CDM","250","RC","","Facility","Outpatient","","","150","120.00","","","","150.00","Fee Schedule","","","","","150.00","Fee Schedule","","","","","150.00","Fee Schedule","","","52","","150.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;102% Medicare Outpatient Cost to Charge Ratio of 52%","129.00","86","","","Percent of Total Billed Charges","neg_dollar:$129","105.00","70","","","Percent of Total Billed Charges","neg_dollar:$105","","52","","150.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","88.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$88.12;102% of Medicaid interim rate","112.50","75","","","Percent of Total Billed Charges","neg_dollar:$112.50","129.00","86","","","Percent of Total Billed Charges","neg_dollar:$129","105.00","70","","","Percent of Total Billed Charges","neg_dollar:$105","85.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$85.49;103.5% of Medicaid interim rate","150.00","150","","","Percent of Total Billed Charges","neg_dollar:$231.90;150% of Medicaid interim rate","120.00","80","","","Percent of Total Billed Charges","neg_dollar:$120;Percent of Total Billed Charges","138.00","92","","","Percent of Total Billed Charges","neg_dollar:$138","78.00","52","","","Percent of Total Billed Charges","neg_dollar:$78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","150.00","Fee Schedule","","78.00","150.00",""
"KERECIS OMEGA3 PER SQ CM LVL 3","Q4158","HCPCS","27005512","CDM","250","RC","","Facility","Outpatient","","","200","160.00","","","","200.00","Fee Schedule","","","","","200.00","Fee Schedule","","","","","200.00","Fee Schedule","","","52","","200.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","104.00","52","","","Percent of Total Billed Charges","neg_dollar:$104;102% Medicare Outpatient Cost to Charge Ratio of 52%","104.00","52","","","Percent of Total Billed Charges","neg_dollar:$104;102% Medicare Outpatient Cost to Charge Ratio of 52%","172.00","86","","","Percent of Total Billed Charges","neg_dollar:$172","140.00","70","","","Percent of Total Billed Charges","neg_dollar:$140","","52","","200.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","117.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$117.49;102% of Medicaid interim rate","150.00","75","","","Percent of Total Billed Charges","neg_dollar:$150","172.00","86","","","Percent of Total Billed Charges","neg_dollar:$172","140.00","70","","","Percent of Total Billed Charges","neg_dollar:$140","113.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$113.99;103.5% of Medicaid interim rate","200.00","150","","","Percent of Total Billed Charges","neg_dollar:$309.21;150% of Medicaid interim rate","160.00","80","","","Percent of Total Billed Charges","neg_dollar:$160;Percent of Total Billed Charges","184.00","92","","","Percent of Total Billed Charges","neg_dollar:$184","104.00","52","","","Percent of Total Billed Charges","neg_dollar:$104;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","200.00","Fee Schedule","","104.00","200.00",""
"KERECIS OMEGA3 PER SQ CM LVL 4","Q4158","HCPCS","27005513","CDM","250","RC","","Facility","Outpatient","","","250","200.00","","","","250.00","Fee Schedule","","","","","250.00","Fee Schedule","","","","","250.00","Fee Schedule","","","52","","250.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","","52","","250.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","146.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$146.87;102% of Medicaid interim rate","187.50","75","","","Percent of Total Billed Charges","neg_dollar:$187.50","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","142.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$142.50;103.5% of Medicaid interim rate","250.00","150","","","Percent of Total Billed Charges","neg_dollar:$386.51;150% of Medicaid interim rate","200.00","80","","","Percent of Total Billed Charges","neg_dollar:$200;Percent of Total Billed Charges","230.00","92","","","Percent of Total Billed Charges","neg_dollar:$230","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","250.00","Fee Schedule","","130.00","250.00",""
"KERECIS OMEGA3 PER SQ CM LVL 5","Q4158","HCPCS","27005514","CDM","250","RC","","Facility","Outpatient","","","300","240.00","","","","300.00","Fee Schedule","","","","","300.00","Fee Schedule","","","","","300.00","Fee Schedule","","","52","","300.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;102% Medicare Outpatient Cost to Charge Ratio of 52%","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;102% Medicare Outpatient Cost to Charge Ratio of 52%","258.00","86","","","Percent of Total Billed Charges","neg_dollar:$258","210.00","70","","","Percent of Total Billed Charges","neg_dollar:$210","","52","","300.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","176.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$176.24;102% of Medicaid interim rate","225.00","75","","","Percent of Total Billed Charges","neg_dollar:$225","258.00","86","","","Percent of Total Billed Charges","neg_dollar:$258","210.00","70","","","Percent of Total Billed Charges","neg_dollar:$210","170.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$170.99;103.5% of Medicaid interim rate","300.00","150","","","Percent of Total Billed Charges","neg_dollar:$463.81;150% of Medicaid interim rate","240.00","80","","","Percent of Total Billed Charges","neg_dollar:$240;Percent of Total Billed Charges","276.00","92","","","Percent of Total Billed Charges","neg_dollar:$276","156.00","52","","","Percent of Total Billed Charges","neg_dollar:$156;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","300.00","Fee Schedule","","156.00","300.00",""
"KERECIS OMEGA3 PER SQ CM LVL 6","Q4158","HCPCS","27005515","CDM","250","RC","","Facility","Outpatient","","","350","280.00","","","","350.00","Fee Schedule","","","","","350.00","Fee Schedule","","","","","350.00","Fee Schedule","","","52","","350.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","182.00","52","","","Percent of Total Billed Charges","neg_dollar:$182;102% Medicare Outpatient Cost to Charge Ratio of 52%","182.00","52","","","Percent of Total Billed Charges","neg_dollar:$182;102% Medicare Outpatient Cost to Charge Ratio of 52%","301.00","86","","","Percent of Total Billed Charges","neg_dollar:$301","244.99","70","","","Percent of Total Billed Charges","neg_dollar:$244.99","","52","","350.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","205.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$205.62;102% of Medicaid interim rate","262.50","75","","","Percent of Total Billed Charges","neg_dollar:$262.50","301.00","86","","","Percent of Total Billed Charges","neg_dollar:$301","244.99","70","","","Percent of Total Billed Charges","neg_dollar:$244.99","199.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$199.49;103.5% of Medicaid interim rate","350.00","150","","","Percent of Total Billed Charges","neg_dollar:$541.11;150% of Medicaid interim rate","280.00","80","","","Percent of Total Billed Charges","neg_dollar:$280;Percent of Total Billed Charges","322.00","92","","","Percent of Total Billed Charges","neg_dollar:$322","182.00","52","","","Percent of Total Billed Charges","neg_dollar:$182;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","350.00","Fee Schedule","","182.00","350.00",""
"KERECIS OMEGA3 PER SQ CM LVL 7","Q4158","HCPCS","27005516","CDM","250","RC","","Facility","Outpatient","","","400","320.00","","","","400.00","Fee Schedule","","","","","400.00","Fee Schedule","","","","","400.00","Fee Schedule","","","52","","400.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","208.00","52","","","Percent of Total Billed Charges","neg_dollar:$208;102% Medicare Outpatient Cost to Charge Ratio of 52%","208.00","52","","","Percent of Total Billed Charges","neg_dollar:$208;102% Medicare Outpatient Cost to Charge Ratio of 52%","344.00","86","","","Percent of Total Billed Charges","neg_dollar:$344","280.00","70","","","Percent of Total Billed Charges","neg_dollar:$280","","52","","400.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","234.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$234.99;102% of Medicaid interim rate","300.00","75","","","Percent of Total Billed Charges","neg_dollar:$300","344.00","86","","","Percent of Total Billed Charges","neg_dollar:$344","280.00","70","","","Percent of Total Billed Charges","neg_dollar:$280","227.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$227.99;103.5% of Medicaid interim rate","400.00","150","","","Percent of Total Billed Charges","neg_dollar:$618.42;150% of Medicaid interim rate","320.00","80","","","Percent of Total Billed Charges","neg_dollar:$320;Percent of Total Billed Charges","368.00","92","","","Percent of Total Billed Charges","neg_dollar:$368","208.00","52","","","Percent of Total Billed Charges","neg_dollar:$208;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","400.00","Fee Schedule","","208.00","400.00",""
"KERECIS OMEGA3 PER SQ CM LVL 8","Q4158","HCPCS","27005517","CDM","250","RC","","Facility","Outpatient","","","450","360.00","","","","450.00","Fee Schedule","","","","","450.00","Fee Schedule","","","","","450.00","Fee Schedule","","","52","","450.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","234.00","52","","","Percent of Total Billed Charges","neg_dollar:$234;102% Medicare Outpatient Cost to Charge Ratio of 52%","234.00","52","","","Percent of Total Billed Charges","neg_dollar:$234;102% Medicare Outpatient Cost to Charge Ratio of 52%","387.00","86","","","Percent of Total Billed Charges","neg_dollar:$387","315.00","70","","","Percent of Total Billed Charges","neg_dollar:$315","","52","","450.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","264.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$264.37;102% of Medicaid interim rate","337.50","75","","","Percent of Total Billed Charges","neg_dollar:$337.50","387.00","86","","","Percent of Total Billed Charges","neg_dollar:$387","315.00","70","","","Percent of Total Billed Charges","neg_dollar:$315","256.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$256.50;103.5% of Medicaid interim rate","450.00","150","","","Percent of Total Billed Charges","neg_dollar:$695.72;150% of Medicaid interim rate","360.00","80","","","Percent of Total Billed Charges","neg_dollar:$360;Percent of Total Billed Charges","414.00","92","","","Percent of Total Billed Charges","neg_dollar:$414","234.00","52","","","Percent of Total Billed Charges","neg_dollar:$234;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","450.00","Fee Schedule","","234.00","450.00",""
"KERECIS OMEGA3 PER SQ CM LVL 9","Q4158","HCPCS","27005518","CDM","250","RC","","Facility","Outpatient","","","500","400.00","","","","500.00","Fee Schedule","","","","","500.00","Fee Schedule","","","","","500.00","Fee Schedule","","","52","","500.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;102% Medicare Outpatient Cost to Charge Ratio of 52%","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;102% Medicare Outpatient Cost to Charge Ratio of 52%","430.00","86","","","Percent of Total Billed Charges","neg_dollar:$430","350.00","70","","","Percent of Total Billed Charges","neg_dollar:$350","","52","","500.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","293.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$293.74;102% of Medicaid interim rate","375.00","75","","","Percent of Total Billed Charges","neg_dollar:$375","430.00","86","","","Percent of Total Billed Charges","neg_dollar:$430","350.00","70","","","Percent of Total Billed Charges","neg_dollar:$350","285.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$285;103.5% of Medicaid interim rate","500.00","150","","","Percent of Total Billed Charges","neg_dollar:$773.02;150% of Medicaid interim rate","400.00","80","","","Percent of Total Billed Charges","neg_dollar:$400;Percent of Total Billed Charges","460.00","92","","","Percent of Total Billed Charges","neg_dollar:$460","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","500.00","Fee Schedule","","260.00","500.00",""
"KERECIS OMEGA3 PER SQ CM LVL 10","Q4158","HCPCS","27005519","CDM","250","RC","","Facility","Outpatient","","","550","440.00","","","","550.00","Fee Schedule","","","","","550.00","Fee Schedule","","","","","550.00","Fee Schedule","","","52","","550.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","286.00","52","","","Percent of Total Billed Charges","neg_dollar:$286;102% Medicare Outpatient Cost to Charge Ratio of 52%","286.00","52","","","Percent of Total Billed Charges","neg_dollar:$286;102% Medicare Outpatient Cost to Charge Ratio of 52%","473.00","86","","","Percent of Total Billed Charges","neg_dollar:$473","385.00","70","","","Percent of Total Billed Charges","neg_dollar:$385","","52","","550.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","323.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$323.12;102% of Medicaid interim rate","412.50","75","","","Percent of Total Billed Charges","neg_dollar:$412.50","473.00","86","","","Percent of Total Billed Charges","neg_dollar:$473","385.00","70","","","Percent of Total Billed Charges","neg_dollar:$385","313.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$313.50;103.5% of Medicaid interim rate","550.00","150","","","Percent of Total Billed Charges","neg_dollar:$850.32;150% of Medicaid interim rate","440.00","80","","","Percent of Total Billed Charges","neg_dollar:$440;Percent of Total Billed Charges","506.00","92","","","Percent of Total Billed Charges","neg_dollar:$506","286.00","52","","","Percent of Total Billed Charges","neg_dollar:$286;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","550.00","Fee Schedule","","286.00","550.00",""
"KERECIS OMEGA3 PER SQ CM LVL 11","Q4158","HCPCS","27005520","CDM","250","RC","","Facility","Outpatient","","","600","480.00","","","","600.00","Fee Schedule","","","","","600.00","Fee Schedule","","","","","600.00","Fee Schedule","","","52","","600.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","312.00","52","","","Percent of Total Billed Charges","neg_dollar:$312;102% Medicare Outpatient Cost to Charge Ratio of 52%","312.00","52","","","Percent of Total Billed Charges","neg_dollar:$312;102% Medicare Outpatient Cost to Charge Ratio of 52%","516.00","86","","","Percent of Total Billed Charges","neg_dollar:$516","420.00","70","","","Percent of Total Billed Charges","neg_dollar:$420","","52","","600.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","352.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$352.49;102% of Medicaid interim rate","450.00","75","","","Percent of Total Billed Charges","neg_dollar:$450","516.00","86","","","Percent of Total Billed Charges","neg_dollar:$516","420.00","70","","","Percent of Total Billed Charges","neg_dollar:$420","341.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$341.99;103.5% of Medicaid interim rate","600.00","150","","","Percent of Total Billed Charges","neg_dollar:$927.63;150% of Medicaid interim rate","480.00","80","","","Percent of Total Billed Charges","neg_dollar:$480;Percent of Total Billed Charges","552.00","92","","","Percent of Total Billed Charges","neg_dollar:$552","312.00","52","","","Percent of Total Billed Charges","neg_dollar:$312;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","600.00","Fee Schedule","","312.00","600.00",""
"KERECIS OMEGA3 PER SQ CM LVL 12","Q4158","HCPCS","27005701","CDM","250","RC","","Facility","Outpatient","","","650","520.00","","","","650.00","Fee Schedule","","","","","650.00","Fee Schedule","","","","","650.00","Fee Schedule","","","52","","650.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","338.00","52","","","Percent of Total Billed Charges","neg_dollar:$338;102% Medicare Outpatient Cost to Charge Ratio of 52%","338.00","52","","","Percent of Total Billed Charges","neg_dollar:$338;102% Medicare Outpatient Cost to Charge Ratio of 52%","559.00","86","","","Percent of Total Billed Charges","neg_dollar:$559","454.99","70","","","Percent of Total Billed Charges","neg_dollar:$454.99","","52","","650.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","381.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$381.87;102% of Medicaid interim rate","487.50","75","","","Percent of Total Billed Charges","neg_dollar:$487.50","559.00","86","","","Percent of Total Billed Charges","neg_dollar:$559","454.99","70","","","Percent of Total Billed Charges","neg_dollar:$454.99","370.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$370.49;103.5% of Medicaid interim rate","650.00","150","","","Percent of Total Billed Charges","neg_dollar:$1004.93;150% of Medicaid interim rate","520.00","80","","","Percent of Total Billed Charges","neg_dollar:$520;Percent of Total Billed Charges","598.00","92","","","Percent of Total Billed Charges","neg_dollar:$598","338.00","52","","","Percent of Total Billed Charges","neg_dollar:$338;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","650.00","Fee Schedule","","338.00","650.00",""
"NUSHIELD PER SQ CM LVL 1","Q4160","HCPCS","27004588","CDM","250","RC","","Facility","Outpatient","","","250","200.00","","","","250.00","Fee Schedule","","","","","250.00","Fee Schedule","","","","","250.00","Fee Schedule","","","52","","250.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","","52","","250.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","146.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$146.87;102% of Medicaid interim rate","187.50","75","","","Percent of Total Billed Charges","neg_dollar:$187.50","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","142.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$142.50;103.5% of Medicaid interim rate","250.00","150","","","Percent of Total Billed Charges","neg_dollar:$386.51;150% of Medicaid interim rate","200.00","80","","","Percent of Total Billed Charges","neg_dollar:$200;Percent of Total Billed Charges","230.00","92","","","Percent of Total Billed Charges","neg_dollar:$230","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","250.00","Fee Schedule","","130.00","250.00",""
"NUSHIELD PER SQ CM LVL 2","Q4160","HCPCS","27004589","CDM","250","RC","","Facility","Outpatient","","","500","400.00","","","","500.00","Fee Schedule","","","","","500.00","Fee Schedule","","","","","500.00","Fee Schedule","","","52","","500.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;102% Medicare Outpatient Cost to Charge Ratio of 52%","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;102% Medicare Outpatient Cost to Charge Ratio of 52%","430.00","86","","","Percent of Total Billed Charges","neg_dollar:$430","350.00","70","","","Percent of Total Billed Charges","neg_dollar:$350","","52","","500.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","293.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$293.74;102% of Medicaid interim rate","375.00","75","","","Percent of Total Billed Charges","neg_dollar:$375","430.00","86","","","Percent of Total Billed Charges","neg_dollar:$430","350.00","70","","","Percent of Total Billed Charges","neg_dollar:$350","285.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$285;103.5% of Medicaid interim rate","500.00","150","","","Percent of Total Billed Charges","neg_dollar:$773.02;150% of Medicaid interim rate","400.00","80","","","Percent of Total Billed Charges","neg_dollar:$400;Percent of Total Billed Charges","460.00","92","","","Percent of Total Billed Charges","neg_dollar:$460","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","500.00","Fee Schedule","","260.00","500.00",""
"NUSHIELD PER SQ CM LVL 3","Q4160","HCPCS","27004590","CDM","250","RC","","Facility","Outpatient","","","750","600.00","","","","750.00","Fee Schedule","","","","","750.00","Fee Schedule","","","","","750.00","Fee Schedule","","","52","","750.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;102% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;102% Medicare Outpatient Cost to Charge Ratio of 52%","645.00","86","","","Percent of Total Billed Charges","neg_dollar:$645","525.00","70","","","Percent of Total Billed Charges","neg_dollar:$525","","52","","750.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","440.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$440.62;102% of Medicaid interim rate","562.50","75","","","Percent of Total Billed Charges","neg_dollar:$562.50","645.00","86","","","Percent of Total Billed Charges","neg_dollar:$645","525.00","70","","","Percent of Total Billed Charges","neg_dollar:$525","427.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$427.49;103.5% of Medicaid interim rate","750.00","150","","","Percent of Total Billed Charges","neg_dollar:$1159.53;150% of Medicaid interim rate","600.00","80","","","Percent of Total Billed Charges","neg_dollar:$600;Percent of Total Billed Charges","690.00","92","","","Percent of Total Billed Charges","neg_dollar:$690","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","750.00","Fee Schedule","","390.00","750.00",""
"NUSHIELD PER SQ CM LVL 4","Q4160","HCPCS","27004591","CDM","250","RC","","Facility","Outpatient","","","1000","800.00","","","","1000.00","Fee Schedule","","","","","1000.00","Fee Schedule","","","","","1000.00","Fee Schedule","","","52","","1000.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","520.00","52","","","Percent of Total Billed Charges","neg_dollar:$520;102% Medicare Outpatient Cost to Charge Ratio of 52%","520.00","52","","","Percent of Total Billed Charges","neg_dollar:$520;102% Medicare Outpatient Cost to Charge Ratio of 52%","860.00","86","","","Percent of Total Billed Charges","neg_dollar:$860","700.00","70","","","Percent of Total Billed Charges","neg_dollar:$700","","52","","1000.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","587.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$587.49;102% of Medicaid interim rate","750.00","75","","","Percent of Total Billed Charges","neg_dollar:$750","860.00","86","","","Percent of Total Billed Charges","neg_dollar:$860","700.00","70","","","Percent of Total Billed Charges","neg_dollar:$700","570.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$570;103.5% of Medicaid interim rate","1000.00","150","","","Percent of Total Billed Charges","neg_dollar:$1546.05;150% of Medicaid interim rate","800.00","80","","","Percent of Total Billed Charges","neg_dollar:$800;Percent of Total Billed Charges","920.00","92","","","Percent of Total Billed Charges","neg_dollar:$920","520.00","52","","","Percent of Total Billed Charges","neg_dollar:$520;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1000.00","Fee Schedule","","520.00","1000.00",""
"NUSHIELD PER SQ CM LVL 5","Q4160","HCPCS","27004592","CDM","250","RC","","Facility","Outpatient","","","1250","1000.00","","","","1250.00","Fee Schedule","","","","","1250.00","Fee Schedule","","","","","1250.00","Fee Schedule","","","52","","1250.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;102% Medicare Outpatient Cost to Charge Ratio of 52%","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;102% Medicare Outpatient Cost to Charge Ratio of 52%","1075.00","86","","","Percent of Total Billed Charges","neg_dollar:$1075","875.00","70","","","Percent of Total Billed Charges","neg_dollar:$875","","52","","1250.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","734.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$734.37;102% of Medicaid interim rate","937.50","75","","","Percent of Total Billed Charges","neg_dollar:$937.50","1075.00","86","","","Percent of Total Billed Charges","neg_dollar:$1075","875.00","70","","","Percent of Total Billed Charges","neg_dollar:$875","712.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$712.49;103.5% of Medicaid interim rate","1250.00","150","","","Percent of Total Billed Charges","neg_dollar:$1932.56;150% of Medicaid interim rate","1000.00","80","","","Percent of Total Billed Charges","neg_dollar:$1000;Percent of Total Billed Charges","1150.00","92","","","Percent of Total Billed Charges","neg_dollar:$1150","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1250.00","Fee Schedule","","650.00","1250.00",""
"NUSHIELD PER SQ CM LVL 6","Q4160","HCPCS","27004593","CDM","250","RC","","Facility","Outpatient","","","1500","1200.00","","","","1500.00","Fee Schedule","","","","","1500.00","Fee Schedule","","","","","1500.00","Fee Schedule","","","52","","1500.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","780.00","52","","","Percent of Total Billed Charges","neg_dollar:$780;102% Medicare Outpatient Cost to Charge Ratio of 52%","780.00","52","","","Percent of Total Billed Charges","neg_dollar:$780;102% Medicare Outpatient Cost to Charge Ratio of 52%","1290.00","86","","","Percent of Total Billed Charges","neg_dollar:$1290","1050.00","70","","","Percent of Total Billed Charges","neg_dollar:$1050","","52","","1500.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","881.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$881.24;102% of Medicaid interim rate","1125.00","75","","","Percent of Total Billed Charges","neg_dollar:$1125","1290.00","86","","","Percent of Total Billed Charges","neg_dollar:$1290","1050.00","70","","","Percent of Total Billed Charges","neg_dollar:$1050","854.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$854.99;103.5% of Medicaid interim rate","1500.00","150","","","Percent of Total Billed Charges","neg_dollar:$2319.07;150% of Medicaid interim rate","1200.00","80","","","Percent of Total Billed Charges","neg_dollar:$1200;Percent of Total Billed Charges","1380.00","92","","","Percent of Total Billed Charges","neg_dollar:$1380","780.00","52","","","Percent of Total Billed Charges","neg_dollar:$780;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1500.00","Fee Schedule","","780.00","1500.00",""
"EPIFIX PER SQ CM LVL 1","Q4186","HCPCS","27004660","CDM","250","RC","","Facility","Outpatient","","","250","200.00","","","","250.00","Fee Schedule","","","","","250.00","Fee Schedule","","","","","250.00","Fee Schedule","","","52","","250.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;102% Medicare Outpatient Cost to Charge Ratio of 52%","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","","52","","250.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","146.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$146.87;102% of Medicaid interim rate","187.50","75","","","Percent of Total Billed Charges","neg_dollar:$187.50","215.00","86","","","Percent of Total Billed Charges","neg_dollar:$215","175.00","70","","","Percent of Total Billed Charges","neg_dollar:$175","142.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$142.50;103.5% of Medicaid interim rate","250.00","150","","","Percent of Total Billed Charges","neg_dollar:$386.51;150% of Medicaid interim rate","200.00","80","","","Percent of Total Billed Charges","neg_dollar:$200;Percent of Total Billed Charges","230.00","92","","","Percent of Total Billed Charges","neg_dollar:$230","130.00","52","","","Percent of Total Billed Charges","neg_dollar:$130;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","250.00","Fee Schedule","","130.00","250.00",""
"EPIFIX PER SQ CM LVL 2","Q4186","HCPCS","27004661","CDM","250","RC","","Facility","Outpatient","","","500","400.00","","","","500.00","Fee Schedule","","","","","500.00","Fee Schedule","","","","","500.00","Fee Schedule","","","52","","500.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;102% Medicare Outpatient Cost to Charge Ratio of 52%","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;102% Medicare Outpatient Cost to Charge Ratio of 52%","430.00","86","","","Percent of Total Billed Charges","neg_dollar:$430","350.00","70","","","Percent of Total Billed Charges","neg_dollar:$350","","52","","500.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","293.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$293.74;102% of Medicaid interim rate","375.00","75","","","Percent of Total Billed Charges","neg_dollar:$375","430.00","86","","","Percent of Total Billed Charges","neg_dollar:$430","350.00","70","","","Percent of Total Billed Charges","neg_dollar:$350","285.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$285;103.5% of Medicaid interim rate","500.00","150","","","Percent of Total Billed Charges","neg_dollar:$773.02;150% of Medicaid interim rate","400.00","80","","","Percent of Total Billed Charges","neg_dollar:$400;Percent of Total Billed Charges","460.00","92","","","Percent of Total Billed Charges","neg_dollar:$460","260.00","52","","","Percent of Total Billed Charges","neg_dollar:$260;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","500.00","Fee Schedule","","260.00","500.00",""
"EPIFIX PER SQ CM LVL 3","Q4186","HCPCS","27004662","CDM","250","RC","","Facility","Outpatient","","","750","600.00","","","","750.00","Fee Schedule","","","","","750.00","Fee Schedule","","","","","750.00","Fee Schedule","","","52","","750.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;102% Medicare Outpatient Cost to Charge Ratio of 52%","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;102% Medicare Outpatient Cost to Charge Ratio of 52%","645.00","86","","","Percent of Total Billed Charges","neg_dollar:$645","525.00","70","","","Percent of Total Billed Charges","neg_dollar:$525","","52","","750.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","440.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$440.62;102% of Medicaid interim rate","562.50","75","","","Percent of Total Billed Charges","neg_dollar:$562.50","645.00","86","","","Percent of Total Billed Charges","neg_dollar:$645","525.00","70","","","Percent of Total Billed Charges","neg_dollar:$525","427.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$427.49;103.5% of Medicaid interim rate","750.00","150","","","Percent of Total Billed Charges","neg_dollar:$1159.53;150% of Medicaid interim rate","600.00","80","","","Percent of Total Billed Charges","neg_dollar:$600;Percent of Total Billed Charges","690.00","92","","","Percent of Total Billed Charges","neg_dollar:$690","390.00","52","","","Percent of Total Billed Charges","neg_dollar:$390;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","750.00","Fee Schedule","","390.00","750.00",""
"EPIFIX PER SQ CM LVL 4","Q4186","HCPCS","27004663","CDM","250","RC","","Facility","Outpatient","","","1000","800.00","","","","1000.00","Fee Schedule","","","","","1000.00","Fee Schedule","","","","","1000.00","Fee Schedule","","","52","","1000.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","520.00","52","","","Percent of Total Billed Charges","neg_dollar:$520;102% Medicare Outpatient Cost to Charge Ratio of 52%","520.00","52","","","Percent of Total Billed Charges","neg_dollar:$520;102% Medicare Outpatient Cost to Charge Ratio of 52%","860.00","86","","","Percent of Total Billed Charges","neg_dollar:$860","700.00","70","","","Percent of Total Billed Charges","neg_dollar:$700","","52","","1000.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","587.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$587.49;102% of Medicaid interim rate","750.00","75","","","Percent of Total Billed Charges","neg_dollar:$750","860.00","86","","","Percent of Total Billed Charges","neg_dollar:$860","700.00","70","","","Percent of Total Billed Charges","neg_dollar:$700","570.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$570;103.5% of Medicaid interim rate","1000.00","150","","","Percent of Total Billed Charges","neg_dollar:$1546.05;150% of Medicaid interim rate","800.00","80","","","Percent of Total Billed Charges","neg_dollar:$800;Percent of Total Billed Charges","920.00","92","","","Percent of Total Billed Charges","neg_dollar:$920","520.00","52","","","Percent of Total Billed Charges","neg_dollar:$520;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1000.00","Fee Schedule","","520.00","1000.00",""
"EPIFIX PER SQ CM LVL 5","Q4186","HCPCS","27004664","CDM","250","RC","","Facility","Outpatient","","","1250","1000.00","","","","1250.00","Fee Schedule","","","","","1250.00","Fee Schedule","","","","","1250.00","Fee Schedule","","","52","","1250.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;102% Medicare Outpatient Cost to Charge Ratio of 52%","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;102% Medicare Outpatient Cost to Charge Ratio of 52%","1075.00","86","","","Percent of Total Billed Charges","neg_dollar:$1075","875.00","70","","","Percent of Total Billed Charges","neg_dollar:$875","","52","","1250.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","734.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$734.37;102% of Medicaid interim rate","937.50","75","","","Percent of Total Billed Charges","neg_dollar:$937.50","1075.00","86","","","Percent of Total Billed Charges","neg_dollar:$1075","875.00","70","","","Percent of Total Billed Charges","neg_dollar:$875","712.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$712.49;103.5% of Medicaid interim rate","1250.00","150","","","Percent of Total Billed Charges","neg_dollar:$1932.56;150% of Medicaid interim rate","1000.00","80","","","Percent of Total Billed Charges","neg_dollar:$1000;Percent of Total Billed Charges","1150.00","92","","","Percent of Total Billed Charges","neg_dollar:$1150","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1250.00","Fee Schedule","","650.00","1250.00",""
"EPIFIX PER SQ CM LVL 6","Q4186","HCPCS","27004665","CDM","250","RC","","Facility","Outpatient","","","1500","1200.00","","","","1500.00","Fee Schedule","","","","","1500.00","Fee Schedule","","","","","1500.00","Fee Schedule","","","52","","1500.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","780.00","52","","","Percent of Total Billed Charges","neg_dollar:$780;102% Medicare Outpatient Cost to Charge Ratio of 52%","780.00","52","","","Percent of Total Billed Charges","neg_dollar:$780;102% Medicare Outpatient Cost to Charge Ratio of 52%","1290.00","86","","","Percent of Total Billed Charges","neg_dollar:$1290","1050.00","70","","","Percent of Total Billed Charges","neg_dollar:$1050","","52","","1500.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","881.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$881.24;102% of Medicaid interim rate","1125.00","75","","","Percent of Total Billed Charges","neg_dollar:$1125","1290.00","86","","","Percent of Total Billed Charges","neg_dollar:$1290","1050.00","70","","","Percent of Total Billed Charges","neg_dollar:$1050","854.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$854.99;103.5% of Medicaid interim rate","1500.00","150","","","Percent of Total Billed Charges","neg_dollar:$2319.07;150% of Medicaid interim rate","1200.00","80","","","Percent of Total Billed Charges","neg_dollar:$1200;Percent of Total Billed Charges","1380.00","92","","","Percent of Total Billed Charges","neg_dollar:$1380","780.00","52","","","Percent of Total Billed Charges","neg_dollar:$780;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1500.00","Fee Schedule","","780.00","1500.00",""
"INFLIXIMAB-DYYB 100 MG IV SOLR","Q5103","HCPCS","00069-0809-01","NDC","636","RC","","Facility","Outpatient","100","ME","191.38","191.38","","","","191.38","Fee Schedule","","","","","191.38","Fee Schedule","101% of Medicare Fee Schedule","","","","191.38","Fee Schedule","","99.52","52","","","Percent of Total Billed Charges","neg_dollar:$99.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","191.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","191.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","164.59","86","","","Percent of Total Billed Charges","neg_dollar:$164.59","133.97","70","","","Percent of Total Billed Charges","neg_dollar:$133.97","99.52","52","","","Percent of Total Billed Charges","neg_dollar:$99.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","112.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$112.44;102% of Medicaid interim rate","143.54","75","","","Percent of Total Billed Charges","neg_dollar:$143.54","164.59","86","","","Percent of Total Billed Charges","neg_dollar:$164.59","133.97","70","","","Percent of Total Billed Charges","neg_dollar:$133.97","109.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$109.09;103.5% of Medicaid interim rate","191.38","150","","","Percent of Total Billed Charges","neg_dollar:$295.89;150% of Medicaid interim rate","153.11","80","","","Percent of Total Billed Charges","neg_dollar:$153.11;Percent of Total Billed Charges","176.07","92","","","Percent of Total Billed Charges","neg_dollar:$176.07","99.52","52","","","Percent of Total Billed Charges","neg_dollar:$99.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","99.52","52","","","Percent of Total Billed Charges","neg_dollar:$99.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","99.00","191.00",""
"INFLIXIMAB-ABDA 100 MG IV SOLR","Q5104","HCPCS","78206-162-01","NDC","636","RC","","Facility","Outpatient","100","ME","153.08","153.08","","","","153.08","Fee Schedule","","","","","153.08","Fee Schedule","101% of Medicare Fee Schedule","","","","153.08","Fee Schedule","","79.60","52","","","Percent of Total Billed Charges","neg_dollar:$79.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","153.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","153.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","131.64","86","","","Percent of Total Billed Charges","neg_dollar:$131.64","107.15","70","","","Percent of Total Billed Charges","neg_dollar:$107.15","79.60","52","","","Percent of Total Billed Charges","neg_dollar:$79.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","89.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$89.93;102% of Medicaid interim rate","114.81","75","","","Percent of Total Billed Charges","neg_dollar:$114.81","131.64","86","","","Percent of Total Billed Charges","neg_dollar:$131.64","107.15","70","","","Percent of Total Billed Charges","neg_dollar:$107.15","87.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$87.25;103.5% of Medicaid interim rate","153.08","150","","","Percent of Total Billed Charges","neg_dollar:$236.67;150% of Medicaid interim rate","122.46","80","","","Percent of Total Billed Charges","neg_dollar:$122.46;Percent of Total Billed Charges","140.83","92","","","Percent of Total Billed Charges","neg_dollar:$140.83","79.60","52","","","Percent of Total Billed Charges","neg_dollar:$79.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","79.60","52","","","Percent of Total Billed Charges","neg_dollar:$79.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","79.00","153.00",""
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","Q5106","HCPCS","00069-1308-10","NDC","636","RC","","Facility","Outpatient","1","ML","26.43","26.43","","","","26.43","Fee Schedule","","","","","26.43","Fee Schedule","101% of Medicare Fee Schedule","","","","26.43","Fee Schedule","","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.73","86","","","Percent of Total Billed Charges","neg_dollar:$22.73","18.50","70","","","Percent of Total Billed Charges","neg_dollar:$18.50","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;105% Medicare Outpatient Cost to Charge Ratio of 52%","15.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.53;102% of Medicaid interim rate","19.82","75","","","Percent of Total Billed Charges","neg_dollar:$19.82","22.73","86","","","Percent of Total Billed Charges","neg_dollar:$22.73","18.50","70","","","Percent of Total Billed Charges","neg_dollar:$18.50","15.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.06;103.5% of Medicaid interim rate","26.43","150","","","Percent of Total Billed Charges","neg_dollar:$40.86;150% of Medicaid interim rate","21.14","80","","","Percent of Total Billed Charges","neg_dollar:$21.14;Percent of Total Billed Charges","24.32","92","","","Percent of Total Billed Charges","neg_dollar:$24.32","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","26.00",""
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","Q5106","HCPCS","00069-1308-01","NDC","636","RC","","Facility","Outpatient","1","ML","26.43","26.43","","","","26.43","Fee Schedule","","","","","26.43","Fee Schedule","101% of Medicare Fee Schedule","","","","26.43","Fee Schedule","","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","26.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","22.73","86","","","Percent of Total Billed Charges","neg_dollar:$22.73","18.50","70","","","Percent of Total Billed Charges","neg_dollar:$18.50","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;105% Medicare Outpatient Cost to Charge Ratio of 52%","15.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.53;102% of Medicaid interim rate","19.82","75","","","Percent of Total Billed Charges","neg_dollar:$19.82","22.73","86","","","Percent of Total Billed Charges","neg_dollar:$22.73","18.50","70","","","Percent of Total Billed Charges","neg_dollar:$18.50","15.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.06;103.5% of Medicaid interim rate","26.43","150","","","Percent of Total Billed Charges","neg_dollar:$40.86;150% of Medicaid interim rate","21.14","80","","","Percent of Total Billed Charges","neg_dollar:$21.14;Percent of Total Billed Charges","24.32","92","","","Percent of Total Billed Charges","neg_dollar:$24.32","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.74","52","","","Percent of Total Billed Charges","neg_dollar:$13.74;100% Medicare Outpatient Cost to Charge Ratio of 52%","13.00","26.00",""
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","Q5106","HCPCS","00069-1308-10","NDC","636","RC","","Facility","Outpatient","1","ML","11.82","11.82","","","","11.82","Fee Schedule","","","","","11.82","Fee Schedule","101% of Medicare Fee Schedule","","","","11.82","Fee Schedule","","6.14","52","","","Percent of Total Billed Charges","neg_dollar:$6.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.16","86","","","Percent of Total Billed Charges","neg_dollar:$10.16","8.27","70","","","Percent of Total Billed Charges","neg_dollar:$8.27","6.14","52","","","Percent of Total Billed Charges","neg_dollar:$6.14;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.94;102% of Medicaid interim rate","8.86","75","","","Percent of Total Billed Charges","neg_dollar:$8.86","10.16","86","","","Percent of Total Billed Charges","neg_dollar:$10.16","8.27","70","","","Percent of Total Billed Charges","neg_dollar:$8.27","6.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.73;103.5% of Medicaid interim rate","11.82","150","","","Percent of Total Billed Charges","neg_dollar:$18.27;150% of Medicaid interim rate","9.45","80","","","Percent of Total Billed Charges","neg_dollar:$9.45;Percent of Total Billed Charges","10.87","92","","","Percent of Total Billed Charges","neg_dollar:$10.87","6.14","52","","","Percent of Total Billed Charges","neg_dollar:$6.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.14","52","","","Percent of Total Billed Charges","neg_dollar:$6.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","11.00",""
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","Q5106","HCPCS","00069-1308-01","NDC","636","RC","","Facility","Outpatient","1","ML","11.69","11.69","","","","11.69","Fee Schedule","","","","","11.69","Fee Schedule","101% of Medicare Fee Schedule","","","","11.69","Fee Schedule","","6.07","52","","","Percent of Total Billed Charges","neg_dollar:$6.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.69","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.69","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.05","86","","","Percent of Total Billed Charges","neg_dollar:$10.05","8.18","70","","","Percent of Total Billed Charges","neg_dollar:$8.18","6.07","52","","","Percent of Total Billed Charges","neg_dollar:$6.07;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.86;102% of Medicaid interim rate","8.76","75","","","Percent of Total Billed Charges","neg_dollar:$8.76","10.05","86","","","Percent of Total Billed Charges","neg_dollar:$10.05","8.18","70","","","Percent of Total Billed Charges","neg_dollar:$8.18","6.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.66;103.5% of Medicaid interim rate","11.69","150","","","Percent of Total Billed Charges","neg_dollar:$18.07;150% of Medicaid interim rate","9.35","80","","","Percent of Total Billed Charges","neg_dollar:$9.35;Percent of Total Billed Charges","10.75","92","","","Percent of Total Billed Charges","neg_dollar:$10.75","6.07","52","","","Percent of Total Billed Charges","neg_dollar:$6.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.07","52","","","Percent of Total Billed Charges","neg_dollar:$6.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","11.00",""
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","Q5106","HCPCS","00069-1308-01","NDC","636","RC","","Facility","Outpatient","1","ML","11.82","11.82","","","","11.82","Fee Schedule","","","","","11.82","Fee Schedule","101% of Medicare Fee Schedule","","","","11.82","Fee Schedule","","6.14","52","","","Percent of Total Billed Charges","neg_dollar:$6.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.16","86","","","Percent of Total Billed Charges","neg_dollar:$10.16","8.27","70","","","Percent of Total Billed Charges","neg_dollar:$8.27","6.14","52","","","Percent of Total Billed Charges","neg_dollar:$6.14;105% Medicare Outpatient Cost to Charge Ratio of 52%","6.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.94;102% of Medicaid interim rate","8.86","75","","","Percent of Total Billed Charges","neg_dollar:$8.86","10.16","86","","","Percent of Total Billed Charges","neg_dollar:$10.16","8.27","70","","","Percent of Total Billed Charges","neg_dollar:$8.27","6.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.73;103.5% of Medicaid interim rate","11.82","150","","","Percent of Total Billed Charges","neg_dollar:$18.27;150% of Medicaid interim rate","9.45","80","","","Percent of Total Billed Charges","neg_dollar:$9.45;Percent of Total Billed Charges","10.87","92","","","Percent of Total Billed Charges","neg_dollar:$10.87","6.14","52","","","Percent of Total Billed Charges","neg_dollar:$6.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.14","52","","","Percent of Total Billed Charges","neg_dollar:$6.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","11.00",""
"EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN","Q5106","HCPCS","00069-1308-01","NDC","636","RC","","Facility","Outpatient","1","ML","28.08","28.08","","","","28.08","Fee Schedule","","","","","28.08","Fee Schedule","101% of Medicare Fee Schedule","","","","28.08","Fee Schedule","","14.60","52","","","Percent of Total Billed Charges","neg_dollar:$14.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","28.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","28.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","24.15","86","","","Percent of Total Billed Charges","neg_dollar:$24.15","19.65","70","","","Percent of Total Billed Charges","neg_dollar:$19.65","14.60","52","","","Percent of Total Billed Charges","neg_dollar:$14.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.49;102% of Medicaid interim rate","21.06","75","","","Percent of Total Billed Charges","neg_dollar:$21.06","24.15","86","","","Percent of Total Billed Charges","neg_dollar:$24.15","19.65","70","","","Percent of Total Billed Charges","neg_dollar:$19.65","16.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$16;103.5% of Medicaid interim rate","28.08","150","","","Percent of Total Billed Charges","neg_dollar:$43.41;150% of Medicaid interim rate","22.46","80","","","Percent of Total Billed Charges","neg_dollar:$22.46;Percent of Total Billed Charges","25.83","92","","","Percent of Total Billed Charges","neg_dollar:$25.83","14.60","52","","","Percent of Total Billed Charges","neg_dollar:$14.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.60","52","","","Percent of Total Billed Charges","neg_dollar:$14.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.00","28.00",""
"EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN","Q5106","HCPCS","00069-1305-01","NDC","636","RC","","Facility","Outpatient","1","ML","27.94","27.94","","","","27.94","Fee Schedule","","","","","27.94","Fee Schedule","101% of Medicare Fee Schedule","","","","27.94","Fee Schedule","","14.52","52","","","Percent of Total Billed Charges","neg_dollar:$14.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","27.94","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","27.94","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","24.03","86","","","Percent of Total Billed Charges","neg_dollar:$24.03","19.55","70","","","Percent of Total Billed Charges","neg_dollar:$19.55","14.52","52","","","Percent of Total Billed Charges","neg_dollar:$14.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.41;102% of Medicaid interim rate","20.95","75","","","Percent of Total Billed Charges","neg_dollar:$20.95","24.03","86","","","Percent of Total Billed Charges","neg_dollar:$24.03","19.55","70","","","Percent of Total Billed Charges","neg_dollar:$19.55","15.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.92;103.5% of Medicaid interim rate","27.94","150","","","Percent of Total Billed Charges","neg_dollar:$43.20;150% of Medicaid interim rate","22.35","80","","","Percent of Total Billed Charges","neg_dollar:$22.35;Percent of Total Billed Charges","25.70","92","","","Percent of Total Billed Charges","neg_dollar:$25.70","14.52","52","","","Percent of Total Billed Charges","neg_dollar:$14.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.52","52","","","Percent of Total Billed Charges","neg_dollar:$14.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.00","27.00",""
"PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY","Q5108","HCPCS","83257-005-41","NDC","250","RC","","Facility","Outpatient","1","UN","355.21","355.21","","","","355.21","Fee Schedule","","","","","355.21","Fee Schedule","","","","","355.21","Fee Schedule","","","52","","355.21","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","184.71","52","","","Percent of Total Billed Charges","neg_dollar:$184.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","184.71","52","","","Percent of Total Billed Charges","neg_dollar:$184.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","305.48","86","","","Percent of Total Billed Charges","neg_dollar:$305.48","248.64","70","","","Percent of Total Billed Charges","neg_dollar:$248.64","","52","","355.21","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","208.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$208.68;102% of Medicaid interim rate","266.40","75","","","Percent of Total Billed Charges","neg_dollar:$266.40","305.48","86","","","Percent of Total Billed Charges","neg_dollar:$305.48","248.64","70","","","Percent of Total Billed Charges","neg_dollar:$248.64","202.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$202.47;103.5% of Medicaid interim rate","355.21","150","","","Percent of Total Billed Charges","neg_dollar:$549.17;150% of Medicaid interim rate","284.17","80","","","Percent of Total Billed Charges","neg_dollar:$284.17;Percent of Total Billed Charges","326.79","92","","","Percent of Total Billed Charges","neg_dollar:$326.79","184.71","52","","","Percent of Total Billed Charges","neg_dollar:$184.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","355.21","Fee Schedule","","184.00","355.00",""
"FILGRASTIM-AAFI 480 MCG/0.8ML IJ SOSY","Q5110","HCPCS","00069-0292-01","NDC","636","RC","","Facility","Outpatient","1","UN","1.64","1.64","","","","1.64","Fee Schedule","","","","","1.64","Fee Schedule","101% of Medicare Fee Schedule","","","","1.64","Fee Schedule","","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.64","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.14","70","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.23","75","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.14","70","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;103.5% of Medicaid interim rate","1.64","150","","","Percent of Total Billed Charges","neg_dollar:$2.53;150% of Medicaid interim rate","1.31","80","","","Percent of Total Billed Charges","neg_dollar:$1.31;Percent of Total Billed Charges","1.51","92","","","Percent of Total Billed Charges","neg_dollar:$1.51","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PEGFILGRASTIM-PBBK 6 MG/0.6ML SC SOSY","Q5130","HCPCS","70121-1627-1","NDC","636","RC","","Facility","Outpatient","1","UN","423.96","423.96","","","","423.96","Fee Schedule","","","","","423.96","Fee Schedule","101% of Medicare Fee Schedule","","","","423.96","Fee Schedule","","220.46","52","","","Percent of Total Billed Charges","neg_dollar:$220.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","423.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","423.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","364.60","86","","","Percent of Total Billed Charges","neg_dollar:$364.60","296.77","70","","","Percent of Total Billed Charges","neg_dollar:$296.77","220.46","52","","","Percent of Total Billed Charges","neg_dollar:$220.46;105% Medicare Outpatient Cost to Charge Ratio of 52%","249.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.07;102% of Medicaid interim rate","317.97","75","","","Percent of Total Billed Charges","neg_dollar:$317.97","364.60","86","","","Percent of Total Billed Charges","neg_dollar:$364.60","296.77","70","","","Percent of Total Billed Charges","neg_dollar:$296.77","241.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$241.65;103.5% of Medicaid interim rate","423.96","150","","","Percent of Total Billed Charges","neg_dollar:$655.46;150% of Medicaid interim rate","339.17","80","","","Percent of Total Billed Charges","neg_dollar:$339.17;Percent of Total Billed Charges","390.04","92","","","Percent of Total Billed Charges","neg_dollar:$390.04","220.46","52","","","Percent of Total Billed Charges","neg_dollar:$220.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.46","52","","","Percent of Total Billed Charges","neg_dollar:$220.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.00","423.00",""
"IOPAMIDOL 61 % IJ SOLN","Q9967","HCPCS","00270-1412-15","NDC","636","RC","","Facility","Outpatient","1","UN","0.01","0.01","","","","0.01","Fee Schedule","","","","","0.01","Fee Schedule","101% of Medicare Fee Schedule","","","","0.01","Fee Schedule","","","52","","0.01","Percent of Total Billed Charges","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","86","","0.01","Percent of Total Billed Charges","","","70","","0.01","Percent of Total Billed Charges","","","52","","0.01","Percent of Total Billed Charges","105% Medicare Outpatient Cost to Charge Ratio of 52%","","56.99","","0.01","Percent of Total Billed Charges","102% of Medicaid interim rate","","75","","0.01","Percent of Total Billed Charges","","","86","","0.01","Percent of Total Billed Charges","","","70","","0.01","Percent of Total Billed Charges","","","56.99","","0.01","Percent of Total Billed Charges","103.5% of Medicaid interim rate","0.01","150","","","Percent of Total Billed Charges","neg_dollar:$0.01;150% of Medicaid interim rate","","80","","0.01","Percent of Total Billed Charges","Percent of Total Billed Charges","","92","","0.01","Percent of Total Billed Charges","","","52","","0.01","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.01","Fee Schedule","101% of Medicare Fee Schedule","1.00","1.00",""
"LOCM 300-399 MG/ML IODINE 1ML","Q9967","HCPCS","27002534","CDM","255","RC","","Facility","Outpatient","1","ML","2","1.60","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"FAMOTIDINE (PF) 20 MG/2ML IV SOLN","S0028","HCPCS","67457-433-00","NDC","636","RC","","Facility","Outpatient","2","ML","89.30","89.30","","","","33.00","Fee Schedule","","","","","45.00","Fee Schedule","101% of Medicare Fee Schedule","","","","1.00","Fee Schedule","","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","89.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","76.79","86","","","Percent of Total Billed Charges","neg_dollar:$76.79","62.50","70","","","Percent of Total Billed Charges","neg_dollar:$62.50","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.46;102% of Medicaid interim rate","66.97","75","","","Percent of Total Billed Charges","neg_dollar:$66.97","76.79","86","","","Percent of Total Billed Charges","neg_dollar:$76.79","62.50","70","","","Percent of Total Billed Charges","neg_dollar:$62.50","50.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.90;103.5% of Medicaid interim rate","89.30","150","","","Percent of Total Billed Charges","neg_dollar:$138.06;150% of Medicaid interim rate","71.44","80","","","Percent of Total Billed Charges","neg_dollar:$71.44;Percent of Total Billed Charges","82.15","92","","","Percent of Total Billed Charges","neg_dollar:$82.15","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","89.00",""
"FINASTERIDE 5 MG PO TABS","S0138","HCPCS","60687-428-11","NDC","250","RC","","Facility","Outpatient","5","ME","2.10","2.10","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","","52","","2.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% of Medicaid interim rate","1.57","75","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.19;103.5% of Medicaid interim rate","2.10","150","","","Percent of Total Billed Charges","neg_dollar:$3.24;150% of Medicaid interim rate","1.68","80","","","Percent of Total Billed Charges","neg_dollar:$1.68;Percent of Total Billed Charges","1.93","92","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.10","Fee Schedule","","1.00","2.00",""
"NICOTINE 14 MG/24HR TD PT24","S4991","HCPCS","00536-5895-88","NDC","250","RC","","Facility","Outpatient","14","ME","3.10","3.10","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","","","52","","3.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","","52","","3.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% of Medicaid interim rate","2.32","75","","","Percent of Total Billed Charges","neg_dollar:$2.32","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","1.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.76;103.5% of Medicaid interim rate","3.10","150","","","Percent of Total Billed Charges","neg_dollar:$4.79;150% of Medicaid interim rate","2.48","80","","","Percent of Total Billed Charges","neg_dollar:$2.48;Percent of Total Billed Charges","2.85","92","","","Percent of Total Billed Charges","neg_dollar:$2.85","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.10","Fee Schedule","","1.00","3.00",""
"NICOTINE 21 MG/24HR TD PT24","S4991","HCPCS","00536-5896-88","NDC","636","RC","","Facility","Outpatient","21","ME","3.10","3.10","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","101% of Medicare Fee Schedule","","","","3.10","Fee Schedule","","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% of Medicaid interim rate","2.32","75","","","Percent of Total Billed Charges","neg_dollar:$2.32","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","1.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.76;103.5% of Medicaid interim rate","3.10","150","","","Percent of Total Billed Charges","neg_dollar:$4.79;150% of Medicaid interim rate","2.48","80","","","Percent of Total Billed Charges","neg_dollar:$2.48;Percent of Total Billed Charges","2.85","92","","","Percent of Total Billed Charges","neg_dollar:$2.85","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SC SOPN","S5551","HCPCS","00002-8799-01","NDC","250","RC","","Facility","Outpatient","1","ML","2.51","2.51","","","","2.51","Fee Schedule","","","","","2.51","Fee Schedule","","","","","2.51","Fee Schedule","","","52","","2.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.16","86","","","Percent of Total Billed Charges","neg_dollar:$2.16","1.76","70","","","Percent of Total Billed Charges","neg_dollar:$1.76","","52","","2.51","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.48;102% of Medicaid interim rate","1.88","75","","","Percent of Total Billed Charges","neg_dollar:$1.88","2.16","86","","","Percent of Total Billed Charges","neg_dollar:$2.16","1.76","70","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.43;103.5% of Medicaid interim rate","2.51","150","","","Percent of Total Billed Charges","neg_dollar:$3.89;150% of Medicaid interim rate","2.01","80","","","Percent of Total Billed Charges","neg_dollar:$2.01;Percent of Total Billed Charges","2.31","92","","","Percent of Total Billed Charges","neg_dollar:$2.31","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.51","Percent of Total Billed Charges","100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"INSULIN GLARGINE 100 UNIT/ML SC SOPN","S5553","HCPCS","00088-2219-05","NDC","636","RC","","Facility","Outpatient","1","ML","44.40","44.40","","","","44.40","Fee Schedule","","","","","44.40","Fee Schedule","101% of Medicare Fee Schedule","","","","44.40","Fee Schedule","","23.08","52","","","Percent of Total Billed Charges","neg_dollar:$23.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","44.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","44.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","38.18","86","","","Percent of Total Billed Charges","neg_dollar:$38.18","31.08","70","","","Percent of Total Billed Charges","neg_dollar:$31.08","23.08","52","","","Percent of Total Billed Charges","neg_dollar:$23.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","26.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.08;102% of Medicaid interim rate","33.30","75","","","Percent of Total Billed Charges","neg_dollar:$33.30","38.18","86","","","Percent of Total Billed Charges","neg_dollar:$38.18","31.08","70","","","Percent of Total Billed Charges","neg_dollar:$31.08","25.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.30;103.5% of Medicaid interim rate","44.40","150","","","Percent of Total Billed Charges","neg_dollar:$68.64;150% of Medicaid interim rate","35.52","80","","","Percent of Total Billed Charges","neg_dollar:$35.52;Percent of Total Billed Charges","40.84","92","","","Percent of Total Billed Charges","neg_dollar:$40.84","23.08","52","","","Percent of Total Billed Charges","neg_dollar:$23.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.08","52","","","Percent of Total Billed Charges","neg_dollar:$23.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","23.00","44.00",""
"INSULIN GLARGINE 100 UNIT/ML SC SOPN","S5553","HCPCS","00088-2219-05","NDC","250","RC","","Facility","Outpatient","1","ML","12.04","12.04","","","","12.04","Fee Schedule","","","","","12.04","Fee Schedule","","","","","12.04","Fee Schedule","","","52","","12.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.26","52","","","Percent of Total Billed Charges","neg_dollar:$6.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.26","52","","","Percent of Total Billed Charges","neg_dollar:$6.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.35","86","","","Percent of Total Billed Charges","neg_dollar:$10.35","8.42","70","","","Percent of Total Billed Charges","neg_dollar:$8.42","","52","","12.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.07;102% of Medicaid interim rate","9.03","75","","","Percent of Total Billed Charges","neg_dollar:$9.03","10.35","86","","","Percent of Total Billed Charges","neg_dollar:$10.35","8.42","70","","","Percent of Total Billed Charges","neg_dollar:$8.42","6.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.86;103.5% of Medicaid interim rate","12.04","150","","","Percent of Total Billed Charges","neg_dollar:$18.61;150% of Medicaid interim rate","9.63","80","","","Percent of Total Billed Charges","neg_dollar:$9.63;Percent of Total Billed Charges","11.07","92","","","Percent of Total Billed Charges","neg_dollar:$11.07","6.26","52","","","Percent of Total Billed Charges","neg_dollar:$6.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.04","Fee Schedule","","6.00","12.00",""
"DIABETES MGMT PROG, GROUP","S9455","HCPCS","90000270","CDM","942","RC","","Facility","Outpatient","","","1466","1172.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","762.32","52","","","Percent of Total Billed Charges","neg_dollar:$762.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","762.32","52","","","Percent of Total Billed Charges","neg_dollar:$762.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","762.32","52","","","Percent of Total Billed Charges","neg_dollar:$762.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","762.32","52","","","Percent of Total Billed Charges","neg_dollar:$762.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1260.76","86","","","Percent of Total Billed Charges","neg_dollar:$1260.76","1026.20","70","","","Percent of Total Billed Charges","neg_dollar:$1026.20","762.32","52","","","Percent of Total Billed Charges","neg_dollar:$762.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","861.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$861.27;102% of Medicaid interim rate","1099.50","75","","","Percent of Total Billed Charges","neg_dollar:$1099.50","1260.76","86","","","Percent of Total Billed Charges","neg_dollar:$1260.76","1026.20","70","","","Percent of Total Billed Charges","neg_dollar:$1026.20","835.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$835.61;103.5% of Medicaid interim rate","1466.00","150","","","Percent of Total Billed Charges","neg_dollar:$2266.50;150% of Medicaid interim rate","1172.80","80","","","Percent of Total Billed Charges","neg_dollar:$1172.80;Percent of Total Billed Charges","1348.72","92","","","Percent of Total Billed Charges","neg_dollar:$1348.72","762.32","52","","","Percent of Total Billed Charges","neg_dollar:$762.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","762.32","52","","","Percent of Total Billed Charges","neg_dollar:$762.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1466.00",""
"DIABETES MGMT PROG, INDIV","S9455","HCPCS","90000387","CDM","942","RC","","Facility","Outpatient","","","1848","1478.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1589.28","86","","","Percent of Total Billed Charges","neg_dollar:$1589.28","1293.60","70","","","Percent of Total Billed Charges","neg_dollar:$1293.60","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","1085.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$1085.69;102% of Medicaid interim rate","1386.00","75","","","Percent of Total Billed Charges","neg_dollar:$1386","1589.28","86","","","Percent of Total Billed Charges","neg_dollar:$1589.28","1293.60","70","","","Percent of Total Billed Charges","neg_dollar:$1293.60","1053.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$1053.36;103.5% of Medicaid interim rate","1848.00","150","","","Percent of Total Billed Charges","neg_dollar:$2857.10;150% of Medicaid interim rate","1478.40","80","","","Percent of Total Billed Charges","neg_dollar:$1478.40;Percent of Total Billed Charges","1700.16","92","","","Percent of Total Billed Charges","neg_dollar:$1700.16","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1848.00",""
"LENS, INTRAOCULAR ANTERIOR LVL 1","V2630","HCPCS","27001884","CDM","276","RC","","Facility","Outpatient","","","537","429.60","537.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","537.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","461.82","86","","","Percent of Total Billed Charges","neg_dollar:$461.82","375.90","70","","","Percent of Total Billed Charges","neg_dollar:$375.90","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","315.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$315.48;102% of Medicaid interim rate","402.75","75","","","Percent of Total Billed Charges","neg_dollar:$402.75","461.82","86","","","Percent of Total Billed Charges","neg_dollar:$461.82","375.90","70","","","Percent of Total Billed Charges","neg_dollar:$375.90","306.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$306.09;103.5% of Medicaid interim rate","537.00","150","","","Percent of Total Billed Charges","neg_dollar:$830.22;150% of Medicaid interim rate","429.60","80","","","Percent of Total Billed Charges","neg_dollar:$429.60;Percent of Total Billed Charges","494.04","92","","","Percent of Total Billed Charges","neg_dollar:$494.04","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.00","537.00",""
"LENS, INTRAOCULAR POSTERIOR LVL 1","V2632","HCPCS","27001895","CDM","276","RC","","Facility","Outpatient","","","537","429.60","537.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","537.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","461.82","86","","","Percent of Total Billed Charges","neg_dollar:$461.82","375.90","70","","","Percent of Total Billed Charges","neg_dollar:$375.90","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","315.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$315.48;102% of Medicaid interim rate","402.75","75","","","Percent of Total Billed Charges","neg_dollar:$402.75","461.82","86","","","Percent of Total Billed Charges","neg_dollar:$461.82","375.90","70","","","Percent of Total Billed Charges","neg_dollar:$375.90","306.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$306.09;103.5% of Medicaid interim rate","537.00","150","","","Percent of Total Billed Charges","neg_dollar:$830.22;150% of Medicaid interim rate","429.60","80","","","Percent of Total Billed Charges","neg_dollar:$429.60;Percent of Total Billed Charges","494.04","92","","","Percent of Total Billed Charges","neg_dollar:$494.04","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.24","52","","","Percent of Total Billed Charges","neg_dollar:$279.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","279.00","537.00",""
"INSULIN NPH ISOPHANE & REGULAR (70-30) 100 UNIT/ML SC SUSP","","","00002-8715-01","NDC","250","RC","","Facility","Outpatient","1","ML","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SC SOPN","","","00002-8799-01","NDC","250","RC","","Facility","Outpatient","1","EA","151.15","151.15","","","","151.15","Fee Schedule","","","","","151.15","Fee Schedule","","","","","151.15","Fee Schedule","","","52","","151.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","78.59","52","","","Percent of Total Billed Charges","neg_dollar:$78.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.59","52","","","Percent of Total Billed Charges","neg_dollar:$78.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","129.98","86","","","Percent of Total Billed Charges","neg_dollar:$129.98","105.80","70","","","Percent of Total Billed Charges","neg_dollar:$105.80","","52","","151.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","88.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$88.80;102% of Medicaid interim rate","113.36","75","","","Percent of Total Billed Charges","neg_dollar:$113.36","129.98","86","","","Percent of Total Billed Charges","neg_dollar:$129.98","105.80","70","","","Percent of Total Billed Charges","neg_dollar:$105.80","86.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$86.15;103.5% of Medicaid interim rate","151.15","150","","","Percent of Total Billed Charges","neg_dollar:$233.68;150% of Medicaid interim rate","120.92","80","","","Percent of Total Billed Charges","neg_dollar:$120.92;Percent of Total Billed Charges","139.05","92","","","Percent of Total Billed Charges","neg_dollar:$139.05","78.59","52","","","Percent of Total Billed Charges","neg_dollar:$78.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","151.15","Fee Schedule","","78.00","151.00",""
"APIXABAN 5 MG PO TABS","","","00003-0894-21","NDC","250","RC","","Facility","Outpatient","5","ME","12.06","12.06","","","","12.06","Fee Schedule","","","","","12.06","Fee Schedule","","","","","12.06","Fee Schedule","","","52","","12.06","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.27","52","","","Percent of Total Billed Charges","neg_dollar:$6.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.27","52","","","Percent of Total Billed Charges","neg_dollar:$6.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.37","86","","","Percent of Total Billed Charges","neg_dollar:$10.37","8.44","70","","","Percent of Total Billed Charges","neg_dollar:$8.44","","52","","12.06","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.08;102% of Medicaid interim rate","9.04","75","","","Percent of Total Billed Charges","neg_dollar:$9.04","10.37","86","","","Percent of Total Billed Charges","neg_dollar:$10.37","8.44","70","","","Percent of Total Billed Charges","neg_dollar:$8.44","6.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.87;103.5% of Medicaid interim rate","12.06","150","","","Percent of Total Billed Charges","neg_dollar:$18.64;150% of Medicaid interim rate","9.64","80","","","Percent of Total Billed Charges","neg_dollar:$9.64;Percent of Total Billed Charges","11.09","92","","","Percent of Total Billed Charges","neg_dollar:$11.09","6.27","52","","","Percent of Total Billed Charges","neg_dollar:$6.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.06","Fee Schedule","","6.00","12.00",""
"APIXABAN 5 MG PO TABS","","","00003-0894-21","NDC","637","RC","","Facility","Outpatient","5","ME","12.90","12.90","","","","12.90","Fee Schedule","","","","","12.90","Fee Schedule","101% of Medicare Fee Schedule","","","","12.90","Fee Schedule","","6.70","52","","","Percent of Total Billed Charges","neg_dollar:$6.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.09","86","","","Percent of Total Billed Charges","neg_dollar:$11.09","9.03","70","","","Percent of Total Billed Charges","neg_dollar:$9.03","6.70","52","","","Percent of Total Billed Charges","neg_dollar:$6.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.57;102% of Medicaid interim rate","9.67","75","","","Percent of Total Billed Charges","neg_dollar:$9.67","11.09","86","","","Percent of Total Billed Charges","neg_dollar:$11.09","9.03","70","","","Percent of Total Billed Charges","neg_dollar:$9.03","7.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.35;103.5% of Medicaid interim rate","12.90","150","","","Percent of Total Billed Charges","neg_dollar:$19.94;150% of Medicaid interim rate","10.32","80","","","Percent of Total Billed Charges","neg_dollar:$10.32;Percent of Total Billed Charges","11.86","92","","","Percent of Total Billed Charges","neg_dollar:$11.86","6.70","52","","","Percent of Total Billed Charges","neg_dollar:$6.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.70","52","","","Percent of Total Billed Charges","neg_dollar:$6.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","12.00",""
"SUGAMMADEX SODIUM 200 MG/2ML IV SOLN","","","00006-5423-12","NDC","250","RC","","Facility","Outpatient","1","UN","234.70","234.70","","","","234.70","Fee Schedule","","","","","234.70","Fee Schedule","","","","","234.70","Fee Schedule","","","52","","234.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","122.04","52","","","Percent of Total Billed Charges","neg_dollar:$122.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","122.04","52","","","Percent of Total Billed Charges","neg_dollar:$122.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","201.84","86","","","Percent of Total Billed Charges","neg_dollar:$201.84","164.29","70","","","Percent of Total Billed Charges","neg_dollar:$164.29","","52","","234.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","137.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$137.88;102% of Medicaid interim rate","176.02","75","","","Percent of Total Billed Charges","neg_dollar:$176.02","201.84","86","","","Percent of Total Billed Charges","neg_dollar:$201.84","164.29","70","","","Percent of Total Billed Charges","neg_dollar:$164.29","133.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$133.77;103.5% of Medicaid interim rate","234.70","150","","","Percent of Total Billed Charges","neg_dollar:$362.85;150% of Medicaid interim rate","187.76","80","","","Percent of Total Billed Charges","neg_dollar:$187.76;Percent of Total Billed Charges","215.92","92","","","Percent of Total Billed Charges","neg_dollar:$215.92","122.04","52","","","Percent of Total Billed Charges","neg_dollar:$122.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","234.70","Fee Schedule","","122.00","234.00",""
"SUGAMMADEX SODIUM 200 MG/2ML IV SOLN","","","00006-5423-12","NDC","250","RC","","Facility","Outpatient","1","EA","39.66","39.66","","","","39.66","Fee Schedule","","","","","39.66","Fee Schedule","","","","","39.66","Fee Schedule","","","52","","39.66","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.62","52","","","Percent of Total Billed Charges","neg_dollar:$20.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.62","52","","","Percent of Total Billed Charges","neg_dollar:$20.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","34.11","86","","","Percent of Total Billed Charges","neg_dollar:$34.11","27.76","70","","","Percent of Total Billed Charges","neg_dollar:$27.76","","52","","39.66","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","23.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$23.30;102% of Medicaid interim rate","29.74","75","","","Percent of Total Billed Charges","neg_dollar:$29.74","34.11","86","","","Percent of Total Billed Charges","neg_dollar:$34.11","27.76","70","","","Percent of Total Billed Charges","neg_dollar:$27.76","22.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.60;103.5% of Medicaid interim rate","39.66","150","","","Percent of Total Billed Charges","neg_dollar:$61.32;150% of Medicaid interim rate","31.73","80","","","Percent of Total Billed Charges","neg_dollar:$31.73;Percent of Total Billed Charges","36.49","92","","","Percent of Total Billed Charges","neg_dollar:$36.49","20.62","52","","","Percent of Total Billed Charges","neg_dollar:$20.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","39.66","Fee Schedule","","20.00","39.00",""
"TRANEXAMIC ACID 1000 MG/10ML IV SOLN","","","00013-1114-20","NDC","250","RC","","Facility","Outpatient","1","UN","114.74","114.74","","","","114.74","Fee Schedule","","","","","114.74","Fee Schedule","","","","","114.74","Fee Schedule","","","52","","114.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","59.66","52","","","Percent of Total Billed Charges","neg_dollar:$59.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","59.66","52","","","Percent of Total Billed Charges","neg_dollar:$59.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","98.67","86","","","Percent of Total Billed Charges","neg_dollar:$98.67","80.31","70","","","Percent of Total Billed Charges","neg_dollar:$80.31","","52","","114.74","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","67.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$67.41;102% of Medicaid interim rate","86.05","75","","","Percent of Total Billed Charges","neg_dollar:$86.05","98.67","86","","","Percent of Total Billed Charges","neg_dollar:$98.67","80.31","70","","","Percent of Total Billed Charges","neg_dollar:$80.31","65.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$65.40;103.5% of Medicaid interim rate","114.74","150","","","Percent of Total Billed Charges","neg_dollar:$177.39;150% of Medicaid interim rate","91.79","80","","","Percent of Total Billed Charges","neg_dollar:$91.79;Percent of Total Billed Charges","105.56","92","","","Percent of Total Billed Charges","neg_dollar:$105.56","59.66","52","","","Percent of Total Billed Charges","neg_dollar:$59.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","114.74","Fee Schedule","","59.00","114.00",""
"PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS PO CPEP","","","00032-1206-01","NDC","250","RC","","Facility","Outpatient","1","UN","3.50","3.50","","","","3.50","Fee Schedule","","","","","3.50","Fee Schedule","","","","","3.50","Fee Schedule","","","52","","3.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","52","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","52","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.01","86","","","Percent of Total Billed Charges","neg_dollar:$3.01","2.44","70","","","Percent of Total Billed Charges","neg_dollar:$2.44","","52","","3.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.05;102% of Medicaid interim rate","2.62","75","","","Percent of Total Billed Charges","neg_dollar:$2.62","3.01","86","","","Percent of Total Billed Charges","neg_dollar:$3.01","2.44","70","","","Percent of Total Billed Charges","neg_dollar:$2.44","1.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.99;103.5% of Medicaid interim rate","3.50","150","","","Percent of Total Billed Charges","neg_dollar:$5.41;150% of Medicaid interim rate","2.80","80","","","Percent of Total Billed Charges","neg_dollar:$2.80;Percent of Total Billed Charges","3.22","92","","","Percent of Total Billed Charges","neg_dollar:$3.22","1.82","52","","","Percent of Total Billed Charges","neg_dollar:$1.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.50","Fee Schedule","","1.00","3.00",""
"LORAZEPAM 2 MG/ML PO CONC","","","00054-3532-44","NDC","250","RC","","Facility","Outpatient","1","ML","8.81","8.81","","","","8.81","Fee Schedule","","","","","8.81","Fee Schedule","","","","","8.81","Fee Schedule","","","52","","8.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.58","52","","","Percent of Total Billed Charges","neg_dollar:$4.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.58","52","","","Percent of Total Billed Charges","neg_dollar:$4.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.58","86","","","Percent of Total Billed Charges","neg_dollar:$7.58","6.17","70","","","Percent of Total Billed Charges","neg_dollar:$6.17","","52","","8.81","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.17;102% of Medicaid interim rate","6.61","75","","","Percent of Total Billed Charges","neg_dollar:$6.61","7.58","86","","","Percent of Total Billed Charges","neg_dollar:$7.58","6.17","70","","","Percent of Total Billed Charges","neg_dollar:$6.17","5.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.02;103.5% of Medicaid interim rate","8.81","150","","","Percent of Total Billed Charges","neg_dollar:$13.63;150% of Medicaid interim rate","7.05","80","","","Percent of Total Billed Charges","neg_dollar:$7.05;Percent of Total Billed Charges","8.11","92","","","Percent of Total Billed Charges","neg_dollar:$8.11","4.58","52","","","Percent of Total Billed Charges","neg_dollar:$4.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","8.81","Fee Schedule","","4.00","8.00",""
"FUROSEMIDE 20 MG PO TABS","","","00054-8297-25","NDC","637","RC","","Facility","Outpatient","20","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FUROSEMIDE 20 MG PO TABS","","","00054-8297-25","NDC","250","RC","","Facility","Outpatient","20","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"FUROSEMIDE 40 MG PO TABS","","","00054-8299-25","NDC","250","RC","","Facility","Outpatient","40","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"POVIDONE-IODINE 5 % OP SOLN","","","00065-0411-30","NDC","250","RC","","Facility","Outpatient","1","EA","30.05","30.05","","","","30.05","Fee Schedule","","","","","30.05","Fee Schedule","","","","","30.05","Fee Schedule","","","52","","30.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.62","52","","","Percent of Total Billed Charges","neg_dollar:$15.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.62","52","","","Percent of Total Billed Charges","neg_dollar:$15.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","25.84","86","","","Percent of Total Billed Charges","neg_dollar:$25.84","21.03","70","","","Percent of Total Billed Charges","neg_dollar:$21.03","","52","","30.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","17.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.65;102% of Medicaid interim rate","22.53","75","","","Percent of Total Billed Charges","neg_dollar:$22.53","25.84","86","","","Percent of Total Billed Charges","neg_dollar:$25.84","21.03","70","","","Percent of Total Billed Charges","neg_dollar:$21.03","17.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.12;103.5% of Medicaid interim rate","30.05","150","","","Percent of Total Billed Charges","neg_dollar:$46.45;150% of Medicaid interim rate","24.04","80","","","Percent of Total Billed Charges","neg_dollar:$24.04;Percent of Total Billed Charges","27.64","92","","","Percent of Total Billed Charges","neg_dollar:$27.64","15.62","52","","","Percent of Total Billed Charges","neg_dollar:$15.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","30.05","Fee Schedule","","15.00","30.00",""
"TETRACAINE HCL 0.5 % OP SOLN","","","00065-0741-14","NDC","250","RC","","Facility","Outpatient","1","EA","22.30","22.30","","","","22.30","Fee Schedule","","","","","22.30","Fee Schedule","","","","","22.30","Fee Schedule","","","52","","22.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.18","86","","","Percent of Total Billed Charges","neg_dollar:$19.18","15.61","70","","","Percent of Total Billed Charges","neg_dollar:$15.61","","52","","22.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.10;102% of Medicaid interim rate","16.73","75","","","Percent of Total Billed Charges","neg_dollar:$16.73","19.18","86","","","Percent of Total Billed Charges","neg_dollar:$19.18","15.61","70","","","Percent of Total Billed Charges","neg_dollar:$15.61","12.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.71;103.5% of Medicaid interim rate","22.30","150","","","Percent of Total Billed Charges","neg_dollar:$34.48;150% of Medicaid interim rate","17.84","80","","","Percent of Total Billed Charges","neg_dollar:$17.84;Percent of Total Billed Charges","20.52","92","","","Percent of Total Billed Charges","neg_dollar:$20.52","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","22.30","Fee Schedule","","11.00","22.00",""
"BSS PLUS IO SOLN","","","00065-0795-15","NDC","250","RC","","Facility","Outpatient","1","EA","14.94","14.94","","","","14.94","Fee Schedule","","","","","14.94","Fee Schedule","","","","","14.94","Fee Schedule","","","52","","14.94","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.77","52","","","Percent of Total Billed Charges","neg_dollar:$7.77;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.77","52","","","Percent of Total Billed Charges","neg_dollar:$7.77;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.85","86","","","Percent of Total Billed Charges","neg_dollar:$12.85","10.46","70","","","Percent of Total Billed Charges","neg_dollar:$10.46","","52","","14.94","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.78;102% of Medicaid interim rate","11.21","75","","","Percent of Total Billed Charges","neg_dollar:$11.21","12.85","86","","","Percent of Total Billed Charges","neg_dollar:$12.85","10.46","70","","","Percent of Total Billed Charges","neg_dollar:$10.46","8.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.52;103.5% of Medicaid interim rate","14.94","150","","","Percent of Total Billed Charges","neg_dollar:$23.11;150% of Medicaid interim rate","11.95","80","","","Percent of Total Billed Charges","neg_dollar:$11.95;Percent of Total Billed Charges","13.75","92","","","Percent of Total Billed Charges","neg_dollar:$13.75","7.77","52","","","Percent of Total Billed Charges","neg_dollar:$7.77;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","14.94","Fee Schedule","","7.00","14.00",""
"SACUBITRIL-VALSARTAN 24-26 MG PO TABS","","","00078-0659-20","NDC","250","RC","","Facility","Outpatient","26","ME","14.80","14.80","","","","14.80","Fee Schedule","","","","","14.80","Fee Schedule","","","","","14.80","Fee Schedule","","","52","","14.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.69","52","","","Percent of Total Billed Charges","neg_dollar:$7.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.69","52","","","Percent of Total Billed Charges","neg_dollar:$7.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.72","86","","","Percent of Total Billed Charges","neg_dollar:$12.72","10.36","70","","","Percent of Total Billed Charges","neg_dollar:$10.36","","52","","14.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.69;102% of Medicaid interim rate","11.10","75","","","Percent of Total Billed Charges","neg_dollar:$11.10","12.72","86","","","Percent of Total Billed Charges","neg_dollar:$12.72","10.36","70","","","Percent of Total Billed Charges","neg_dollar:$10.36","8.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.43;103.5% of Medicaid interim rate","14.80","150","","","Percent of Total Billed Charges","neg_dollar:$22.88;150% of Medicaid interim rate","11.84","80","","","Percent of Total Billed Charges","neg_dollar:$11.84;Percent of Total Billed Charges","13.61","92","","","Percent of Total Billed Charges","neg_dollar:$13.61","7.69","52","","","Percent of Total Billed Charges","neg_dollar:$7.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","14.80","Fee Schedule","","7.00","14.00",""
"SACUBITRIL-VALSARTAN 24-26 MG PO TABS","","","00078-0659-20","NDC","637","RC","","Facility","Outpatient","26","ME","14.80","14.80","","","","14.80","Fee Schedule","","","","","14.80","Fee Schedule","101% of Medicare Fee Schedule","","","","14.80","Fee Schedule","","7.69","52","","","Percent of Total Billed Charges","neg_dollar:$7.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","14.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","14.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.72","86","","","Percent of Total Billed Charges","neg_dollar:$12.72","10.36","70","","","Percent of Total Billed Charges","neg_dollar:$10.36","7.69","52","","","Percent of Total Billed Charges","neg_dollar:$7.69;105% Medicare Outpatient Cost to Charge Ratio of 52%","8.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.69;102% of Medicaid interim rate","11.10","75","","","Percent of Total Billed Charges","neg_dollar:$11.10","12.72","86","","","Percent of Total Billed Charges","neg_dollar:$12.72","10.36","70","","","Percent of Total Billed Charges","neg_dollar:$10.36","8.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.43;103.5% of Medicaid interim rate","14.80","150","","","Percent of Total Billed Charges","neg_dollar:$22.88;150% of Medicaid interim rate","11.84","80","","","Percent of Total Billed Charges","neg_dollar:$11.84;Percent of Total Billed Charges","13.61","92","","","Percent of Total Billed Charges","neg_dollar:$13.61","7.69","52","","","Percent of Total Billed Charges","neg_dollar:$7.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.69","52","","","Percent of Total Billed Charges","neg_dollar:$7.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","14.00",""
"INSULIN GLARGINE 100 UNIT/ML SC SOPN","","","00088-2219-05","NDC","637","RC","","Facility","Outpatient","1","EA","90.10","90.10","","","","90.10","Fee Schedule","","","","","90.10","Fee Schedule","101% of Medicare Fee Schedule","","","","90.10","Fee Schedule","","46.85","52","","","Percent of Total Billed Charges","neg_dollar:$46.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","90.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","77.48","86","","","Percent of Total Billed Charges","neg_dollar:$77.48","63.06","70","","","Percent of Total Billed Charges","neg_dollar:$63.06","46.85","52","","","Percent of Total Billed Charges","neg_dollar:$46.85;105% Medicare Outpatient Cost to Charge Ratio of 52%","52.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.93;102% of Medicaid interim rate","67.57","75","","","Percent of Total Billed Charges","neg_dollar:$67.57","77.48","86","","","Percent of Total Billed Charges","neg_dollar:$77.48","63.06","70","","","Percent of Total Billed Charges","neg_dollar:$63.06","51.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.35;103.5% of Medicaid interim rate","90.10","150","","","Percent of Total Billed Charges","neg_dollar:$139.29;150% of Medicaid interim rate","72.08","80","","","Percent of Total Billed Charges","neg_dollar:$72.08;Percent of Total Billed Charges","82.89","92","","","Percent of Total Billed Charges","neg_dollar:$82.89","46.85","52","","","Percent of Total Billed Charges","neg_dollar:$46.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.85","52","","","Percent of Total Billed Charges","neg_dollar:$46.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","46.00","90.00",""
"INSULIN GLARGINE 100 UNIT/ML SC SOPN","","","00088-2219-05","NDC","250","RC","","Facility","Outpatient","1","EA","89.58","89.58","","","","89.58","Fee Schedule","","","","","89.58","Fee Schedule","","","","","89.58","Fee Schedule","","","52","","89.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.58","52","","","Percent of Total Billed Charges","neg_dollar:$46.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.58","52","","","Percent of Total Billed Charges","neg_dollar:$46.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","77.04","86","","","Percent of Total Billed Charges","neg_dollar:$77.04","62.70","70","","","Percent of Total Billed Charges","neg_dollar:$62.70","","52","","89.58","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.63;102% of Medicaid interim rate","67.18","75","","","Percent of Total Billed Charges","neg_dollar:$67.18","77.04","86","","","Percent of Total Billed Charges","neg_dollar:$77.04","62.70","70","","","Percent of Total Billed Charges","neg_dollar:$62.70","51.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.06;103.5% of Medicaid interim rate","89.58","150","","","Percent of Total Billed Charges","neg_dollar:$138.50;150% of Medicaid interim rate","71.66","80","","","Percent of Total Billed Charges","neg_dollar:$71.66;Percent of Total Billed Charges","82.41","92","","","Percent of Total Billed Charges","neg_dollar:$82.41","46.58","52","","","Percent of Total Billed Charges","neg_dollar:$46.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","89.58","Fee Schedule","","46.00","89.00",""
"DILTIAZEM HCL 30 MG PO TABS","","","00093-0318-01","NDC","637","RC","","Facility","Outpatient","30","ME","0.70","0.70","","","","0.70","Fee Schedule","","","","","0.70","Fee Schedule","101% of Medicare Fee Schedule","","","","0.70","Fee Schedule","","0.36","52","","","Percent of Total Billed Charges","neg_dollar:$0.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","86","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.48","70","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.36","52","","","Percent of Total Billed Charges","neg_dollar:$0.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% of Medicaid interim rate","0.52","75","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.60","86","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.48","70","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.39;103.5% of Medicaid interim rate","0.70","150","","","Percent of Total Billed Charges","neg_dollar:$1.08;150% of Medicaid interim rate","0.55","80","","","Percent of Total Billed Charges","neg_dollar:$0.55;Percent of Total Billed Charges","0.64","92","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.36","52","","","Percent of Total Billed Charges","neg_dollar:$0.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","52","","","Percent of Total Billed Charges","neg_dollar:$0.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METOCLOPRAMIDE HCL 10 MG PO TABS","","","00093-2203-01","NDC","250","RC","","Facility","Outpatient","10","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"AMOXICILLIN 500 MG PO CAPS","","","00093-3109-53","NDC","250","RC","","Facility","Outpatient","500","ME","0.72","0.72","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","52","","0.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","","52","","0.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% of Medicaid interim rate","0.54","75","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.41;103.5% of Medicaid interim rate","0.72","150","","","Percent of Total Billed Charges","neg_dollar:$1.12;150% of Medicaid interim rate","0.58","80","","","Percent of Total Billed Charges","neg_dollar:$0.58;Percent of Total Billed Charges","0.66","92","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.72","Fee Schedule","","1.00","1.00",""
"CEPHALEXIN 250 MG/5ML PO SUSR","","","00093-4177-73","NDC","250","RC","","Facility","Outpatient","1","UN","35.80","35.80","","","","35.80","Fee Schedule","","","","","35.80","Fee Schedule","","","","","35.80","Fee Schedule","","","52","","35.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","18.61","52","","","Percent of Total Billed Charges","neg_dollar:$18.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.61","52","","","Percent of Total Billed Charges","neg_dollar:$18.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.78","86","","","Percent of Total Billed Charges","neg_dollar:$30.78","25.05","70","","","Percent of Total Billed Charges","neg_dollar:$25.05","","52","","35.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","21.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.03;102% of Medicaid interim rate","26.84","75","","","Percent of Total Billed Charges","neg_dollar:$26.84","30.78","86","","","Percent of Total Billed Charges","neg_dollar:$30.78","25.05","70","","","Percent of Total Billed Charges","neg_dollar:$25.05","20.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.40;103.5% of Medicaid interim rate","35.80","150","","","Percent of Total Billed Charges","neg_dollar:$55.34;150% of Medicaid interim rate","28.64","80","","","Percent of Total Billed Charges","neg_dollar:$28.64;Percent of Total Billed Charges","32.93","92","","","Percent of Total Billed Charges","neg_dollar:$32.93","18.61","52","","","Percent of Total Billed Charges","neg_dollar:$18.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","35.80","Fee Schedule","","18.00","35.00",""
"LORAZEPAM 2 MG/ML PO CONC","","","00121-0770-01","NDC","250","RC","","Facility","Outpatient","1","ML","10.80","10.80","","","","10.80","Fee Schedule","","","","","10.80","Fee Schedule","","","","","10.80","Fee Schedule","","","52","","10.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.61","52","","","Percent of Total Billed Charges","neg_dollar:$5.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.61","52","","","Percent of Total Billed Charges","neg_dollar:$5.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.28","86","","","Percent of Total Billed Charges","neg_dollar:$9.28","7.56","70","","","Percent of Total Billed Charges","neg_dollar:$7.56","","52","","10.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.34;102% of Medicaid interim rate","8.10","75","","","Percent of Total Billed Charges","neg_dollar:$8.10","9.28","86","","","Percent of Total Billed Charges","neg_dollar:$9.28","7.56","70","","","Percent of Total Billed Charges","neg_dollar:$7.56","6.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.15;103.5% of Medicaid interim rate","10.80","150","","","Percent of Total Billed Charges","neg_dollar:$16.69;150% of Medicaid interim rate","8.64","80","","","Percent of Total Billed Charges","neg_dollar:$8.64;Percent of Total Billed Charges","9.93","92","","","Percent of Total Billed Charges","neg_dollar:$9.93","5.61","52","","","Percent of Total Billed Charges","neg_dollar:$5.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.80","Fee Schedule","","5.00","10.00",""
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD","","","00121-0865-30","NDC","250","RC","","Facility","Outpatient","1","UN","10.22","10.22","","","","10.22","Fee Schedule","","","","","10.22","Fee Schedule","","","","","10.22","Fee Schedule","","","52","","10.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.31","52","","","Percent of Total Billed Charges","neg_dollar:$5.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.31","52","","","Percent of Total Billed Charges","neg_dollar:$5.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.79","86","","","Percent of Total Billed Charges","neg_dollar:$8.79","7.15","70","","","Percent of Total Billed Charges","neg_dollar:$7.15","","52","","10.22","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$6;102% of Medicaid interim rate","7.66","75","","","Percent of Total Billed Charges","neg_dollar:$7.66","8.79","86","","","Percent of Total Billed Charges","neg_dollar:$8.79","7.15","70","","","Percent of Total Billed Charges","neg_dollar:$7.15","5.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.82;103.5% of Medicaid interim rate","10.22","150","","","Percent of Total Billed Charges","neg_dollar:$15.80;150% of Medicaid interim rate","8.18","80","","","Percent of Total Billed Charges","neg_dollar:$8.18;Percent of Total Billed Charges","9.40","92","","","Percent of Total Billed Charges","neg_dollar:$9.40","5.31","52","","","Percent of Total Billed Charges","neg_dollar:$5.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.22","Fee Schedule","","5.00","10.00",""
"LACTULOSE 10 GM/15ML PO SOLN","","","00121-1154-00","NDC","250","RC","","Facility","Outpatient","10","UN","2.10","2.10","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","","52","","2.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% of Medicaid interim rate","1.57","75","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.19;103.5% of Medicaid interim rate","2.10","150","","","Percent of Total Billed Charges","neg_dollar:$3.24;150% of Medicaid interim rate","1.68","80","","","Percent of Total Billed Charges","neg_dollar:$1.68;Percent of Total Billed Charges","1.93","92","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.10","Fee Schedule","","1.00","2.00",""
"ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP","","","00121-1761-30","NDC","637","RC","","Facility","Outpatient","1","UN","3.55","3.55","","","","3.55","Fee Schedule","","","","","3.55","Fee Schedule","101% of Medicare Fee Schedule","","","","3.55","Fee Schedule","","1.84","52","","","Percent of Total Billed Charges","neg_dollar:$1.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.05","86","","","Percent of Total Billed Charges","neg_dollar:$3.05","2.48","70","","","Percent of Total Billed Charges","neg_dollar:$2.48","1.84","52","","","Percent of Total Billed Charges","neg_dollar:$1.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% of Medicaid interim rate","2.66","75","","","Percent of Total Billed Charges","neg_dollar:$2.66","3.05","86","","","Percent of Total Billed Charges","neg_dollar:$3.05","2.48","70","","","Percent of Total Billed Charges","neg_dollar:$2.48","2.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.02;103.5% of Medicaid interim rate","3.55","150","","","Percent of Total Billed Charges","neg_dollar:$5.48;150% of Medicaid interim rate","2.84","80","","","Percent of Total Billed Charges","neg_dollar:$2.84;Percent of Total Billed Charges","3.26","92","","","Percent of Total Billed Charges","neg_dollar:$3.26","1.84","52","","","Percent of Total Billed Charges","neg_dollar:$1.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.84","52","","","Percent of Total Billed Charges","neg_dollar:$1.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","3.00",""
"ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP","","","00121-1761-30","NDC","250","RC","","Facility","Outpatient","1","UN","3.05","3.05","","","","3.05","Fee Schedule","","","","","3.05","Fee Schedule","","","","","3.05","Fee Schedule","","","52","","3.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","52","","","Percent of Total Billed Charges","neg_dollar:$1.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","52","","","Percent of Total Billed Charges","neg_dollar:$1.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","86","","","Percent of Total Billed Charges","neg_dollar:$2.62","2.13","70","","","Percent of Total Billed Charges","neg_dollar:$2.13","","52","","3.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.79;102% of Medicaid interim rate","2.28","75","","","Percent of Total Billed Charges","neg_dollar:$2.28","2.62","86","","","Percent of Total Billed Charges","neg_dollar:$2.62","2.13","70","","","Percent of Total Billed Charges","neg_dollar:$2.13","1.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.73;103.5% of Medicaid interim rate","3.05","150","","","Percent of Total Billed Charges","neg_dollar:$4.71;150% of Medicaid interim rate","2.44","80","","","Percent of Total Billed Charges","neg_dollar:$2.44;Percent of Total Billed Charges","2.80","92","","","Percent of Total Billed Charges","neg_dollar:$2.80","1.58","52","","","Percent of Total Billed Charges","neg_dollar:$1.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.05","Fee Schedule","","1.00","3.00",""
"LIDOCAINE VISCOUS HCL 2 % MT SOLN","","","00121-4950-15","NDC","250","RC","","Facility","Outpatient","1","UN","8.09","8.09","","","","8.09","Fee Schedule","","","","","8.09","Fee Schedule","","","","","8.09","Fee Schedule","","","52","","8.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.21","52","","","Percent of Total Billed Charges","neg_dollar:$4.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.21","52","","","Percent of Total Billed Charges","neg_dollar:$4.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.96","86","","","Percent of Total Billed Charges","neg_dollar:$6.96","5.66","70","","","Percent of Total Billed Charges","neg_dollar:$5.66","","52","","8.09","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","4.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.75;102% of Medicaid interim rate","6.07","75","","","Percent of Total Billed Charges","neg_dollar:$6.07","6.96","86","","","Percent of Total Billed Charges","neg_dollar:$6.96","5.66","70","","","Percent of Total Billed Charges","neg_dollar:$5.66","4.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.61;103.5% of Medicaid interim rate","8.09","150","","","Percent of Total Billed Charges","neg_dollar:$12.51;150% of Medicaid interim rate","6.47","80","","","Percent of Total Billed Charges","neg_dollar:$6.47;Percent of Total Billed Charges","7.44","92","","","Percent of Total Billed Charges","neg_dollar:$7.44","4.21","52","","","Percent of Total Billed Charges","neg_dollar:$4.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","8.09","Fee Schedule","","4.00","8.00",""
"LIDOCAINE VISCOUS HCL 2 % MT SOLN","","","00121-4950-15","NDC","637","RC","","Facility","Outpatient","1","UN","8.40","8.40","","","","8.40","Fee Schedule","","","","","8.40","Fee Schedule","101% of Medicare Fee Schedule","","","","8.40","Fee Schedule","","4.36","52","","","Percent of Total Billed Charges","neg_dollar:$4.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","8.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.22","86","","","Percent of Total Billed Charges","neg_dollar:$7.22","5.88","70","","","Percent of Total Billed Charges","neg_dollar:$5.88","4.36","52","","","Percent of Total Billed Charges","neg_dollar:$4.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","4.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.93;102% of Medicaid interim rate","6.30","75","","","Percent of Total Billed Charges","neg_dollar:$6.30","7.22","86","","","Percent of Total Billed Charges","neg_dollar:$7.22","5.88","70","","","Percent of Total Billed Charges","neg_dollar:$5.88","4.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.78;103.5% of Medicaid interim rate","8.40","150","","","Percent of Total Billed Charges","neg_dollar:$12.98;150% of Medicaid interim rate","6.72","80","","","Percent of Total Billed Charges","neg_dollar:$6.72;Percent of Total Billed Charges","7.72","92","","","Percent of Total Billed Charges","neg_dollar:$7.72","4.36","52","","","Percent of Total Billed Charges","neg_dollar:$4.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.36","52","","","Percent of Total Billed Charges","neg_dollar:$4.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","8.00",""
"CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA","","","00168-0258-46","NDC","250","RC","","Facility","Outpatient","1","UN","50.45","50.45","","","","50.45","Fee Schedule","","","","","50.45","Fee Schedule","","","","","50.45","Fee Schedule","","","52","","50.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","26.23","52","","","Percent of Total Billed Charges","neg_dollar:$26.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.23","52","","","Percent of Total Billed Charges","neg_dollar:$26.23;102% Medicare Outpatient Cost to Charge Ratio of 52%","43.38","86","","","Percent of Total Billed Charges","neg_dollar:$43.38","35.31","70","","","Percent of Total Billed Charges","neg_dollar:$35.31","","52","","50.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","29.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.63;102% of Medicaid interim rate","37.83","75","","","Percent of Total Billed Charges","neg_dollar:$37.83","43.38","86","","","Percent of Total Billed Charges","neg_dollar:$43.38","35.31","70","","","Percent of Total Billed Charges","neg_dollar:$35.31","28.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.75;103.5% of Medicaid interim rate","50.45","150","","","Percent of Total Billed Charges","neg_dollar:$77.99;150% of Medicaid interim rate","40.36","80","","","Percent of Total Billed Charges","neg_dollar:$40.36;Percent of Total Billed Charges","46.41","92","","","Percent of Total Billed Charges","neg_dollar:$46.41","26.23","52","","","Percent of Total Billed Charges","neg_dollar:$26.23;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","50.45","Fee Schedule","","26.00","50.00",""
"LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA","","","00168-0357-05","NDC","250","RC","","Facility","Outpatient","1","EA","19.60","19.60","","","","19.60","Fee Schedule","","","","","19.60","Fee Schedule","","","","","19.60","Fee Schedule","","","52","","19.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.19","52","","","Percent of Total Billed Charges","neg_dollar:$10.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.19","52","","","Percent of Total Billed Charges","neg_dollar:$10.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.85","86","","","Percent of Total Billed Charges","neg_dollar:$16.85","13.72","70","","","Percent of Total Billed Charges","neg_dollar:$13.72","","52","","19.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","11.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.51;102% of Medicaid interim rate","14.70","75","","","Percent of Total Billed Charges","neg_dollar:$14.70","16.85","86","","","Percent of Total Billed Charges","neg_dollar:$16.85","13.72","70","","","Percent of Total Billed Charges","neg_dollar:$13.72","11.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.17;103.5% of Medicaid interim rate","19.60","150","","","Percent of Total Billed Charges","neg_dollar:$30.30;150% of Medicaid interim rate","15.68","80","","","Percent of Total Billed Charges","neg_dollar:$15.68;Percent of Total Billed Charges","18.03","92","","","Percent of Total Billed Charges","neg_dollar:$18.03","10.19","52","","","Percent of Total Billed Charges","neg_dollar:$10.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","19.60","Fee Schedule","","10.00","19.00",""
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","","","00173-0682-24","NDC","250","RC","","Facility","Outpatient","1","UN","35.50","35.50","","","","35.50","Fee Schedule","","","","","35.50","Fee Schedule","","","","","35.50","Fee Schedule","","","52","","35.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","18.46","52","","","Percent of Total Billed Charges","neg_dollar:$18.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.46","52","","","Percent of Total Billed Charges","neg_dollar:$18.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.53","86","","","Percent of Total Billed Charges","neg_dollar:$30.53","24.84","70","","","Percent of Total Billed Charges","neg_dollar:$24.84","","52","","35.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","20.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.85;102% of Medicaid interim rate","26.62","75","","","Percent of Total Billed Charges","neg_dollar:$26.62","30.53","86","","","Percent of Total Billed Charges","neg_dollar:$30.53","24.84","70","","","Percent of Total Billed Charges","neg_dollar:$24.84","20.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.23;103.5% of Medicaid interim rate","35.50","150","","","Percent of Total Billed Charges","neg_dollar:$54.88;150% of Medicaid interim rate","28.40","80","","","Percent of Total Billed Charges","neg_dollar:$28.40;Percent of Total Billed Charges","32.66","92","","","Percent of Total Billed Charges","neg_dollar:$32.66","18.46","52","","","Percent of Total Billed Charges","neg_dollar:$18.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","35.50","Fee Schedule","","18.00","35.00",""
"NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS","","","00185-0122-01","NDC","250","RC","","Facility","Outpatient","100","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"POTASSIUM CHLORIDE CRYS ER 10 MEQ PO TBCR","","","00245-5317-01","NDC","250","RC","","Facility","Outpatient","10","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"POTASSIUM CHLORIDE CRYS ER 10 MEQ PO TBCR","","","00245-5317-89","NDC","250","RC","","Facility","Outpatient","10","ME","0.89","0.89","","","","0.89","Fee Schedule","","","","","0.89","Fee Schedule","","","","","0.89","Fee Schedule","","","52","","0.89","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","70","","","Percent of Total Billed Charges","neg_dollar:$0.62","","52","","0.89","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% of Medicaid interim rate","0.67","75","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","70","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.89","150","","","Percent of Total Billed Charges","neg_dollar:$1.38;150% of Medicaid interim rate","0.71","80","","","Percent of Total Billed Charges","neg_dollar:$0.71;Percent of Total Billed Charges","0.82","92","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.89","Fee Schedule","","1.00","1.00",""
"POTASSIUM CHLORIDE CRYS ER 10 MEQ PO TBCR","","","00245-5317-89","NDC","250","RC","","Facility","Outpatient","10","EA","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","","52","","0.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% of Medicaid interim rate","0.63","75","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.31;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.85","Fee Schedule","","1.00","1.00",""
"POTASSIUM CHLORIDE CRYS ER 10 MEQ PO TBCR","","","00245-5317-89","NDC","637","RC","","Facility","Outpatient","10","EA","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","101% of Medicare Fee Schedule","","","","0.85","Fee Schedule","","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% of Medicaid interim rate","0.63","75","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.31;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SODIUM CHLORIDE 0.9 % IV SOLN","","","00264-1800-31","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.9% IV SOLN MINI-BAG PLUS","","","00264-1800-32","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN","","","00264-7612-00","NDC","250","RC","","Facility","Outpatient","1","EA","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"NITROGLYCERIN 2 % TD OINT","","","00281-0326-08","NDC","637","RC","","Facility","Outpatient","1","UN","2.50","2.50","","","","2.50","Fee Schedule","","","","","2.50","Fee Schedule","101% of Medicare Fee Schedule","","","","2.50","Fee Schedule","","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.15","86","","","Percent of Total Billed Charges","neg_dollar:$2.15","1.75","70","","","Percent of Total Billed Charges","neg_dollar:$1.75","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.46;102% of Medicaid interim rate","1.87","75","","","Percent of Total Billed Charges","neg_dollar:$1.87","2.15","86","","","Percent of Total Billed Charges","neg_dollar:$2.15","1.75","70","","","Percent of Total Billed Charges","neg_dollar:$1.75","1.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.42;103.5% of Medicaid interim rate","2.50","150","","","Percent of Total Billed Charges","neg_dollar:$3.86;150% of Medicaid interim rate","2.00","80","","","Percent of Total Billed Charges","neg_dollar:$2;Percent of Total Billed Charges","2.30","92","","","Percent of Total Billed Charges","neg_dollar:$2.30","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","52","","","Percent of Total Billed Charges","neg_dollar:$1.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
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"SODIUM CHLORIDE 0.9 % IV BOLUS","","","00338-0049-02","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.9 % IV SOLN","","","00338-0049-02","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.9% IV SOLN VIAL-MATE","","","00338-0049-38","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.9 % IV SOLN","","","00338-0049-38","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.9 % IV SOLN","","","00338-0049-41","NDC","250","RC","","Facility","Outpatient","1","UN","54.54","54.54","","","","54.54","Fee Schedule","","","","","54.54","Fee Schedule","","","","","54.54","Fee Schedule","","","52","","54.54","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.36","52","","","Percent of Total Billed Charges","neg_dollar:$28.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.36","52","","","Percent of Total Billed Charges","neg_dollar:$28.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.90","86","","","Percent of Total Billed Charges","neg_dollar:$46.90","38.18","70","","","Percent of Total Billed Charges","neg_dollar:$38.18","","52","","54.54","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","32.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.04;102% of Medicaid interim rate","40.90","75","","","Percent of Total Billed Charges","neg_dollar:$40.90","46.90","86","","","Percent of Total Billed Charges","neg_dollar:$46.90","38.18","70","","","Percent of Total Billed Charges","neg_dollar:$38.18","31.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.09;103.5% of Medicaid interim rate","54.54","150","","","Percent of Total Billed Charges","neg_dollar:$84.32;150% of Medicaid interim rate","43.63","80","","","Percent of Total Billed Charges","neg_dollar:$43.63;Percent of Total Billed Charges","50.18","92","","","Percent of Total Billed Charges","neg_dollar:$50.18","28.36","52","","","Percent of Total Billed Charges","neg_dollar:$28.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","54.54","Fee Schedule","","28.00","54.00",""
"SODIUM CHLORIDE 0.9% IV SOLN VIAL-MATE","","","00338-0049-48","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.9 % IV SOLN","","","00338-0049-48","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.9% IV SOLN MINI-BAG PLUS","","","00338-0049-48","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN","","","00338-0126-12","NDC","250","RC","","Facility","Outpatient","1","EA","157.50","157.50","","","","157.50","Fee Schedule","","","","","157.50","Fee Schedule","","","","","157.50","Fee Schedule","","","52","","157.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","81.90","52","","","Percent of Total Billed Charges","neg_dollar:$81.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","81.90","52","","","Percent of Total Billed Charges","neg_dollar:$81.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","135.45","86","","","Percent of Total Billed Charges","neg_dollar:$135.45","110.25","70","","","Percent of Total Billed Charges","neg_dollar:$110.25","","52","","157.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","92.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$92.53;102% of Medicaid interim rate","118.12","75","","","Percent of Total Billed Charges","neg_dollar:$118.12","135.45","86","","","Percent of Total Billed Charges","neg_dollar:$135.45","110.25","70","","","Percent of Total Billed Charges","neg_dollar:$110.25","89.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$89.77;103.5% of Medicaid interim rate","157.50","150","","","Percent of Total Billed Charges","neg_dollar:$243.50;150% of Medicaid interim rate","126.00","80","","","Percent of Total Billed Charges","neg_dollar:$126;Percent of Total Billed Charges","144.90","92","","","Percent of Total Billed Charges","neg_dollar:$144.90","81.90","52","","","Percent of Total Billed Charges","neg_dollar:$81.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","157.50","Fee Schedule","","81.00","157.00",""
"PLASMA-LYTE A IV SOLN","","","00338-0221-04","NDC","250","RC","","Facility","Outpatient","1","EA","52.94","52.94","","","","52.94","Fee Schedule","","","","","52.94","Fee Schedule","","","","","52.94","Fee Schedule","","","52","","52.94","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","27.52","52","","","Percent of Total Billed Charges","neg_dollar:$27.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.52","52","","","Percent of Total Billed Charges","neg_dollar:$27.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.52","86","","","Percent of Total Billed Charges","neg_dollar:$45.52","37.05","70","","","Percent of Total Billed Charges","neg_dollar:$37.05","","52","","52.94","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","31.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.10;102% of Medicaid interim rate","39.70","75","","","Percent of Total Billed Charges","neg_dollar:$39.70","45.52","86","","","Percent of Total Billed Charges","neg_dollar:$45.52","37.05","70","","","Percent of Total Billed Charges","neg_dollar:$37.05","30.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.17;103.5% of Medicaid interim rate","52.94","150","","","Percent of Total Billed Charges","neg_dollar:$81.84;150% of Medicaid interim rate","42.35","80","","","Percent of Total Billed Charges","neg_dollar:$42.35;Percent of Total Billed Charges","48.70","92","","","Percent of Total Billed Charges","neg_dollar:$48.70","27.52","52","","","Percent of Total Billed Charges","neg_dollar:$27.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","52.94","Fee Schedule","","27.00","52.00",""
"SODIUM CHLORIDE 0.9 % IV SOLN","","","00338-0553-11","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN","","","00338-7032-01","NDC","250","RC","","Facility","Outpatient","1","EA","216.50","216.50","","","","216.50","Fee Schedule","","","","","216.50","Fee Schedule","","","","","216.50","Fee Schedule","","","52","","216.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","112.58","52","","","Percent of Total Billed Charges","neg_dollar:$112.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","112.58","52","","","Percent of Total Billed Charges","neg_dollar:$112.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","186.19","86","","","Percent of Total Billed Charges","neg_dollar:$186.19","151.54","70","","","Percent of Total Billed Charges","neg_dollar:$151.54","","52","","216.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","127.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$127.19;102% of Medicaid interim rate","162.37","75","","","Percent of Total Billed Charges","neg_dollar:$162.37","186.19","86","","","Percent of Total Billed Charges","neg_dollar:$186.19","151.54","70","","","Percent of Total Billed Charges","neg_dollar:$151.54","123.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$123.40;103.5% of Medicaid interim rate","216.50","150","","","Percent of Total Billed Charges","neg_dollar:$334.71;150% of Medicaid interim rate","173.20","80","","","Percent of Total Billed Charges","neg_dollar:$173.20;Percent of Total Billed Charges","199.18","92","","","Percent of Total Billed Charges","neg_dollar:$199.18","112.58","52","","","Percent of Total Billed Charges","neg_dollar:$112.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","216.50","Fee Schedule","","112.00","216.00",""
"SCOPOLAMINE 1 MG/3DAYS TD PT72","","","00378-6470-99","NDC","250","RC","","Facility","Outpatient","1","EA","20.40","20.40","","","","20.40","Fee Schedule","","","","","20.40","Fee Schedule","","","","","20.40","Fee Schedule","","","52","","20.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.54","86","","","Percent of Total Billed Charges","neg_dollar:$17.54","14.27","70","","","Percent of Total Billed Charges","neg_dollar:$14.27","","52","","20.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","11.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.98;102% of Medicaid interim rate","15.29","75","","","Percent of Total Billed Charges","neg_dollar:$15.29","17.54","86","","","Percent of Total Billed Charges","neg_dollar:$17.54","14.27","70","","","Percent of Total Billed Charges","neg_dollar:$14.27","11.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.62;103.5% of Medicaid interim rate","20.40","150","","","Percent of Total Billed Charges","neg_dollar:$31.53;150% of Medicaid interim rate","16.32","80","","","Percent of Total Billed Charges","neg_dollar:$16.32;Percent of Total Billed Charges","18.76","92","","","Percent of Total Billed Charges","neg_dollar:$18.76","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","20.40","Fee Schedule","","10.00","20.00",""
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","","","00406-0123-23","NDC","250","RC","","Facility","Outpatient","1","EA","2.19","2.19","","","","2.19","Fee Schedule","","","","","2.19","Fee Schedule","","","","","2.19","Fee Schedule","","","52","","2.19","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","52","","","Percent of Total Billed Charges","neg_dollar:$1.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","52","","","Percent of Total Billed Charges","neg_dollar:$1.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.88","86","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.53","70","","","Percent of Total Billed Charges","neg_dollar:$1.53","","52","","2.19","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.29;102% of Medicaid interim rate","1.64","75","","","Percent of Total Billed Charges","neg_dollar:$1.64","1.88","86","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.53","70","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.25;103.5% of Medicaid interim rate","2.19","150","","","Percent of Total Billed Charges","neg_dollar:$3.39;150% of Medicaid interim rate","1.75","80","","","Percent of Total Billed Charges","neg_dollar:$1.75;Percent of Total Billed Charges","2.02","92","","","Percent of Total Billed Charges","neg_dollar:$2.02","1.14","52","","","Percent of Total Billed Charges","neg_dollar:$1.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.19","Fee Schedule","","1.00","2.00",""
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","","","00406-0123-23","NDC","637","RC","","Facility","Outpatient","1","EA","2.24","2.24","","","","2.24","Fee Schedule","","","","","2.24","Fee Schedule","101% of Medicare Fee Schedule","","","","2.24","Fee Schedule","","1.16","52","","","Percent of Total Billed Charges","neg_dollar:$1.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.24","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.24","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.92","86","","","Percent of Total Billed Charges","neg_dollar:$1.92","1.56","70","","","Percent of Total Billed Charges","neg_dollar:$1.56","1.16","52","","","Percent of Total Billed Charges","neg_dollar:$1.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.31;102% of Medicaid interim rate","1.68","75","","","Percent of Total Billed Charges","neg_dollar:$1.68","1.92","86","","","Percent of Total Billed Charges","neg_dollar:$1.92","1.56","70","","","Percent of Total Billed Charges","neg_dollar:$1.56","1.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.27;103.5% of Medicaid interim rate","2.24","150","","","Percent of Total Billed Charges","neg_dollar:$3.46;150% of Medicaid interim rate","1.79","80","","","Percent of Total Billed Charges","neg_dollar:$1.79;Percent of Total Billed Charges","2.06","92","","","Percent of Total Billed Charges","neg_dollar:$2.06","1.16","52","","","Percent of Total Billed Charges","neg_dollar:$1.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","52","","","Percent of Total Billed Charges","neg_dollar:$1.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"MORPHINE SULFATE (CONCENTRATE) 20 MG/ML PO SOLN","","","00406-8003-30","NDC","250","RC","","Facility","Outpatient","1","UN","1.58","1.58","","","","1.58","Fee Schedule","","","","","1.58","Fee Schedule","","","","","1.58","Fee Schedule","","","52","","1.58","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.36","86","","","Percent of Total Billed Charges","neg_dollar:$1.36","1.10","70","","","Percent of Total Billed Charges","neg_dollar:$1.10","","52","","1.58","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.18","75","","","Percent of Total Billed Charges","neg_dollar:$1.18","1.36","86","","","Percent of Total Billed Charges","neg_dollar:$1.36","1.10","70","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.90;103.5% of Medicaid interim rate","1.58","150","","","Percent of Total Billed Charges","neg_dollar:$2.44;150% of Medicaid interim rate","1.26","80","","","Percent of Total Billed Charges","neg_dollar:$1.26;Percent of Total Billed Charges","1.45","92","","","Percent of Total Billed Charges","neg_dollar:$1.45","0.82","52","","","Percent of Total Billed Charges","neg_dollar:$0.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.58","Fee Schedule","","1.00","1.00",""
"FENTANYL 50 MCG/HR TD PT72","","","00406-9150-76","NDC","250","RC","","Facility","Outpatient","1","UN","15.70","15.70","","","","15.70","Fee Schedule","","","","","15.70","Fee Schedule","","","","","15.70","Fee Schedule","","","52","","15.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.50","86","","","Percent of Total Billed Charges","neg_dollar:$13.50","10.98","70","","","Percent of Total Billed Charges","neg_dollar:$10.98","","52","","15.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.22;102% of Medicaid interim rate","11.77","75","","","Percent of Total Billed Charges","neg_dollar:$11.77","13.50","86","","","Percent of Total Billed Charges","neg_dollar:$13.50","10.98","70","","","Percent of Total Billed Charges","neg_dollar:$10.98","8.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.94;103.5% of Medicaid interim rate","15.70","150","","","Percent of Total Billed Charges","neg_dollar:$24.27;150% of Medicaid interim rate","12.56","80","","","Percent of Total Billed Charges","neg_dollar:$12.56;Percent of Total Billed Charges","14.44","92","","","Percent of Total Billed Charges","neg_dollar:$14.44","8.16","52","","","Percent of Total Billed Charges","neg_dollar:$8.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","15.70","Fee Schedule","","8.00","15.00",""
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN","","","00409-1749-10","NDC","250","RC","","Facility","Outpatient","1","EA","47.70","47.70","","","","47.70","Fee Schedule","","","","","47.70","Fee Schedule","","","","","47.70","Fee Schedule","","","52","","47.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","24.80","52","","","Percent of Total Billed Charges","neg_dollar:$24.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.80","52","","","Percent of Total Billed Charges","neg_dollar:$24.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","41.02","86","","","Percent of Total Billed Charges","neg_dollar:$41.02","33.39","70","","","Percent of Total Billed Charges","neg_dollar:$33.39","","52","","47.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","28.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.02;102% of Medicaid interim rate","35.77","75","","","Percent of Total Billed Charges","neg_dollar:$35.77","41.02","86","","","Percent of Total Billed Charges","neg_dollar:$41.02","33.39","70","","","Percent of Total Billed Charges","neg_dollar:$33.39","27.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.18;103.5% of Medicaid interim rate","47.70","150","","","Percent of Total Billed Charges","neg_dollar:$73.74;150% of Medicaid interim rate","38.16","80","","","Percent of Total Billed Charges","neg_dollar:$38.16;Percent of Total Billed Charges","43.88","92","","","Percent of Total Billed Charges","neg_dollar:$43.88","24.80","52","","","Percent of Total Billed Charges","neg_dollar:$24.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","47.70","Fee Schedule","","24.00","47.00",""
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN","","","00409-1749-10","NDC","250","RC","","Facility","Outpatient","1","EA","2","2.00","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","","52","","2.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.00","Fee Schedule","","1.00","2.00",""
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN","","","00409-1749-29","NDC","250","RC","","Facility","Outpatient","1","EA","1","1.00","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","","","","","1.00","Fee Schedule","","","52","","1.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","","52","","1.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% of Medicaid interim rate","0.75","75","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.86","86","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.70","70","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.00","150","","","Percent of Total Billed Charges","neg_dollar:$1.54;150% of Medicaid interim rate","0.80","80","","","Percent of Total Billed Charges","neg_dollar:$0.80;Percent of Total Billed Charges","0.92","92","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.00","Fee Schedule","","1.00","1.00",""
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN","","","00409-1749-29","NDC","250","RC","","Facility","Outpatient","1","EA","97.38","97.38","","","","97.38","Fee Schedule","","","","","97.38","Fee Schedule","","","","","97.38","Fee Schedule","","","52","","97.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","50.63","52","","","Percent of Total Billed Charges","neg_dollar:$50.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.63","52","","","Percent of Total Billed Charges","neg_dollar:$50.63;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.74","86","","","Percent of Total Billed Charges","neg_dollar:$83.74","68.16","70","","","Percent of Total Billed Charges","neg_dollar:$68.16","","52","","97.38","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","57.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.21;102% of Medicaid interim rate","73.03","75","","","Percent of Total Billed Charges","neg_dollar:$73.03","83.74","86","","","Percent of Total Billed Charges","neg_dollar:$83.74","68.16","70","","","Percent of Total Billed Charges","neg_dollar:$68.16","55.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.50;103.5% of Medicaid interim rate","97.38","150","","","Percent of Total Billed Charges","neg_dollar:$150.55;150% of Medicaid interim rate","77.90","80","","","Percent of Total Billed Charges","neg_dollar:$77.90;Percent of Total Billed Charges","89.59","92","","","Percent of Total Billed Charges","neg_dollar:$89.59","50.63","52","","","Percent of Total Billed Charges","neg_dollar:$50.63;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","97.38","Fee Schedule","","50.00","97.00",""
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN","","","00409-1749-71","NDC","250","RC","","Facility","Outpatient","1","EA","98.04","98.04","","","","98.04","Fee Schedule","","","","","98.04","Fee Schedule","","","","","98.04","Fee Schedule","","","52","","98.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","50.98","52","","","Percent of Total Billed Charges","neg_dollar:$50.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.98","52","","","Percent of Total Billed Charges","neg_dollar:$50.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","84.31","86","","","Percent of Total Billed Charges","neg_dollar:$84.31","68.63","70","","","Percent of Total Billed Charges","neg_dollar:$68.63","","52","","98.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","57.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.60;102% of Medicaid interim rate","73.53","75","","","Percent of Total Billed Charges","neg_dollar:$73.53","84.31","86","","","Percent of Total Billed Charges","neg_dollar:$84.31","68.63","70","","","Percent of Total Billed Charges","neg_dollar:$68.63","55.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.88;103.5% of Medicaid interim rate","98.04","150","","","Percent of Total Billed Charges","neg_dollar:$151.58;150% of Medicaid interim rate","78.43","80","","","Percent of Total Billed Charges","neg_dollar:$78.43;Percent of Total Billed Charges","90.20","92","","","Percent of Total Billed Charges","neg_dollar:$90.20","50.98","52","","","Percent of Total Billed Charges","neg_dollar:$50.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","98.04","Fee Schedule","","50.00","98.00",""
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN","","","00409-1749-71","NDC","250","RC","","Facility","Outpatient","1","EA","2.20","2.20","","","","2.20","Fee Schedule","","","","","2.20","Fee Schedule","","","","","2.20","Fee Schedule","","","52","","2.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","52","","","Percent of Total Billed Charges","neg_dollar:$1.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","52","","","Percent of Total Billed Charges","neg_dollar:$1.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.89","86","","","Percent of Total Billed Charges","neg_dollar:$1.89","1.54","70","","","Percent of Total Billed Charges","neg_dollar:$1.54","","52","","2.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.29;102% of Medicaid interim rate","1.65","75","","","Percent of Total Billed Charges","neg_dollar:$1.65","1.89","86","","","Percent of Total Billed Charges","neg_dollar:$1.89","1.54","70","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.25;103.5% of Medicaid interim rate","2.20","150","","","Percent of Total Billed Charges","neg_dollar:$3.40;150% of Medicaid interim rate","1.76","80","","","Percent of Total Billed Charges","neg_dollar:$1.76;Percent of Total Billed Charges","2.02","92","","","Percent of Total Billed Charges","neg_dollar:$2.02","1.14","52","","","Percent of Total Billed Charges","neg_dollar:$1.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.20","Fee Schedule","","1.00","2.00",""
"METOPROLOL TARTRATE 5 MG/5ML IV SOLN","","","00409-1778-15","NDC","250","RC","","Facility","Outpatient","1","EA","90","90.00","","","","90.00","Fee Schedule","","","","","90.00","Fee Schedule","","","","","90.00","Fee Schedule","","","52","","90.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","","52","","90.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.87;102% of Medicaid interim rate","67.50","75","","","Percent of Total Billed Charges","neg_dollar:$67.50","77.40","86","","","Percent of Total Billed Charges","neg_dollar:$77.40","62.99","70","","","Percent of Total Billed Charges","neg_dollar:$62.99","51.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.30;103.5% of Medicaid interim rate","90.00","150","","","Percent of Total Billed Charges","neg_dollar:$139.14;150% of Medicaid interim rate","72.00","80","","","Percent of Total Billed Charges","neg_dollar:$72;Percent of Total Billed Charges","82.80","92","","","Percent of Total Billed Charges","neg_dollar:$82.80","46.80","52","","","Percent of Total Billed Charges","neg_dollar:$46.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","90.00","Fee Schedule","","46.00","90.00",""
"SODIUM CHLORIDE 0.9 % IV SOLN","","","00409-4888-02","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM BICARBONATE 4.2 % IV SOLN","","","00409-5534-24","NDC","250","RC","","Facility","Outpatient","1","EA","91.55","91.55","","","","91.55","Fee Schedule","","","","","91.55","Fee Schedule","","","","","91.55","Fee Schedule","","","52","","91.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.60","52","","","Percent of Total Billed Charges","neg_dollar:$47.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.60","52","","","Percent of Total Billed Charges","neg_dollar:$47.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.73","86","","","Percent of Total Billed Charges","neg_dollar:$78.73","64.08","70","","","Percent of Total Billed Charges","neg_dollar:$64.08","","52","","91.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.78;102% of Medicaid interim rate","68.66","75","","","Percent of Total Billed Charges","neg_dollar:$68.66","78.73","86","","","Percent of Total Billed Charges","neg_dollar:$78.73","64.08","70","","","Percent of Total Billed Charges","neg_dollar:$64.08","52.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.18;103.5% of Medicaid interim rate","91.55","150","","","Percent of Total Billed Charges","neg_dollar:$141.54;150% of Medicaid interim rate","73.24","80","","","Percent of Total Billed Charges","neg_dollar:$73.24;Percent of Total Billed Charges","84.22","92","","","Percent of Total Billed Charges","neg_dollar:$84.22","47.60","52","","","Percent of Total Billed Charges","neg_dollar:$47.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","91.55","Fee Schedule","","47.00","91.00",""
"SODIUM BICARBONATE 8.4 % IV SOLN","","","00409-6637-14","NDC","250","RC","","Facility","Outpatient","1","EA","82.15","82.15","","","","82.15","Fee Schedule","","","","","82.15","Fee Schedule","","","","","82.15","Fee Schedule","","","52","","82.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","42.71","52","","","Percent of Total Billed Charges","neg_dollar:$42.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","42.71","52","","","Percent of Total Billed Charges","neg_dollar:$42.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","70.64","86","","","Percent of Total Billed Charges","neg_dollar:$70.64","57.50","70","","","Percent of Total Billed Charges","neg_dollar:$57.50","","52","","82.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","48.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$48.26;102% of Medicaid interim rate","61.61","75","","","Percent of Total Billed Charges","neg_dollar:$61.61","70.64","86","","","Percent of Total Billed Charges","neg_dollar:$70.64","57.50","70","","","Percent of Total Billed Charges","neg_dollar:$57.50","46.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$46.82;103.5% of Medicaid interim rate","82.15","150","","","Percent of Total Billed Charges","neg_dollar:$127;150% of Medicaid interim rate","65.72","80","","","Percent of Total Billed Charges","neg_dollar:$65.72;Percent of Total Billed Charges","75.57","92","","","Percent of Total Billed Charges","neg_dollar:$75.57","42.71","52","","","Percent of Total Billed Charges","neg_dollar:$42.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","82.15","Fee Schedule","","42.00","82.00",""
"SODIUM BICARBONATE 8.4 % IV SOLN","","","00409-6637-24","NDC","250","RC","","Facility","Outpatient","1","EA","113.23","113.23","","","","113.23","Fee Schedule","","","","","113.23","Fee Schedule","","","","","113.23","Fee Schedule","","","52","","113.23","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","58.88","52","","","Percent of Total Billed Charges","neg_dollar:$58.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.88","52","","","Percent of Total Billed Charges","neg_dollar:$58.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","97.38","86","","","Percent of Total Billed Charges","neg_dollar:$97.38","79.26","70","","","Percent of Total Billed Charges","neg_dollar:$79.26","","52","","113.23","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","66.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.52;102% of Medicaid interim rate","84.92","75","","","Percent of Total Billed Charges","neg_dollar:$84.92","97.38","86","","","Percent of Total Billed Charges","neg_dollar:$97.38","79.26","70","","","Percent of Total Billed Charges","neg_dollar:$79.26","64.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.54;103.5% of Medicaid interim rate","113.23","150","","","Percent of Total Billed Charges","neg_dollar:$175.06;150% of Medicaid interim rate","90.58","80","","","Percent of Total Billed Charges","neg_dollar:$90.58;Percent of Total Billed Charges","104.17","92","","","Percent of Total Billed Charges","neg_dollar:$104.17","58.88","52","","","Percent of Total Billed Charges","neg_dollar:$58.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","113.23","Fee Schedule","","58.00","113.00",""
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","","","00409-6651-06","NDC","250","RC","","Facility","Outpatient","1","UN","95.15","95.15","","","","95.15","Fee Schedule","","","","","95.15","Fee Schedule","","","","","95.15","Fee Schedule","","","52","","95.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","49.47","52","","","Percent of Total Billed Charges","neg_dollar:$49.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","49.47","52","","","Percent of Total Billed Charges","neg_dollar:$49.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","81.82","86","","","Percent of Total Billed Charges","neg_dollar:$81.82","66.60","70","","","Percent of Total Billed Charges","neg_dollar:$66.60","","52","","95.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","55.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.90;102% of Medicaid interim rate","71.36","75","","","Percent of Total Billed Charges","neg_dollar:$71.36","81.82","86","","","Percent of Total Billed Charges","neg_dollar:$81.82","66.60","70","","","Percent of Total Billed Charges","neg_dollar:$66.60","54.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.23;103.5% of Medicaid interim rate","95.15","150","","","Percent of Total Billed Charges","neg_dollar:$147.10;150% of Medicaid interim rate","76.12","80","","","Percent of Total Billed Charges","neg_dollar:$76.12;Percent of Total Billed Charges","87.53","92","","","Percent of Total Billed Charges","neg_dollar:$87.53","49.47","52","","","Percent of Total Billed Charges","neg_dollar:$49.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","95.15","Fee Schedule","","49.00","95.00",""
"DEXTROSE 50 % IV SOLN","","","00409-7517-66","NDC","250","RC","","Facility","Outpatient","1","EA","118.91","118.91","","","","118.91","Fee Schedule","","","","","118.91","Fee Schedule","","","","","118.91","Fee Schedule","","","52","","118.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","61.83","52","","","Percent of Total Billed Charges","neg_dollar:$61.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","61.83","52","","","Percent of Total Billed Charges","neg_dollar:$61.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","102.26","86","","","Percent of Total Billed Charges","neg_dollar:$102.26","83.23","70","","","Percent of Total Billed Charges","neg_dollar:$83.23","","52","","118.91","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","69.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$69.86;102% of Medicaid interim rate","89.18","75","","","Percent of Total Billed Charges","neg_dollar:$89.18","102.26","86","","","Percent of Total Billed Charges","neg_dollar:$102.26","83.23","70","","","Percent of Total Billed Charges","neg_dollar:$83.23","67.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$67.78;103.5% of Medicaid interim rate","118.91","150","","","Percent of Total Billed Charges","neg_dollar:$183.84;150% of Medicaid interim rate","95.13","80","","","Percent of Total Billed Charges","neg_dollar:$95.13;Percent of Total Billed Charges","109.39","92","","","Percent of Total Billed Charges","neg_dollar:$109.39","61.83","52","","","Percent of Total Billed Charges","neg_dollar:$61.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","118.91","Fee Schedule","","61.00","118.00",""
"LACTATED RINGERS IV BOLUS","","","00409-7953-09","NDC","250","RC","","Facility","Outpatient","1","EA","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN","","","00487-0201-01","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"RACEPINEPHRINE HCL 2.25 % IN NEBU","","","00487-2784-01","NDC","250","RC","","Facility","Outpatient","1","EA","12.70","12.70","","","","12.70","Fee Schedule","","","","","12.70","Fee Schedule","","","","","12.70","Fee Schedule","","","52","","12.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.60","52","","","Percent of Total Billed Charges","neg_dollar:$6.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.60","52","","","Percent of Total Billed Charges","neg_dollar:$6.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.92","86","","","Percent of Total Billed Charges","neg_dollar:$10.92","8.88","70","","","Percent of Total Billed Charges","neg_dollar:$8.88","","52","","12.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.46;102% of Medicaid interim rate","9.52","75","","","Percent of Total Billed Charges","neg_dollar:$9.52","10.92","86","","","Percent of Total Billed Charges","neg_dollar:$10.92","8.88","70","","","Percent of Total Billed Charges","neg_dollar:$8.88","7.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.23;103.5% of Medicaid interim rate","12.70","150","","","Percent of Total Billed Charges","neg_dollar:$19.63;150% of Medicaid interim rate","10.16","80","","","Percent of Total Billed Charges","neg_dollar:$10.16;Percent of Total Billed Charges","11.68","92","","","Percent of Total Billed Charges","neg_dollar:$11.68","6.60","52","","","Percent of Total Billed Charges","neg_dollar:$6.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","12.70","Fee Schedule","","6.00","12.00",""
"RACEPINEPHRINE HCL 2.25 % IN NEBU","","","00487-5901-99","NDC","250","RC","","Facility","Outpatient","1","EA","3.40","3.40","","","","3.40","Fee Schedule","","","","","3.40","Fee Schedule","","","","","3.40","Fee Schedule","","","52","","3.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.92","86","","","Percent of Total Billed Charges","neg_dollar:$2.92","2.38","70","","","Percent of Total Billed Charges","neg_dollar:$2.38","","52","","3.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.99;102% of Medicaid interim rate","2.55","75","","","Percent of Total Billed Charges","neg_dollar:$2.55","2.92","86","","","Percent of Total Billed Charges","neg_dollar:$2.92","2.38","70","","","Percent of Total Billed Charges","neg_dollar:$2.38","1.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.93;103.5% of Medicaid interim rate","3.40","150","","","Percent of Total Billed Charges","neg_dollar:$5.25;150% of Medicaid interim rate","2.72","80","","","Percent of Total Billed Charges","neg_dollar:$2.72;Percent of Total Billed Charges","3.12","92","","","Percent of Total Billed Charges","neg_dollar:$3.12","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.40","Fee Schedule","","1.00","3.00",""
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU","","","00487-9501-01","NDC","250","RC","","Facility","Outpatient","1","EA","1.33","1.33","","","","1.33","Fee Schedule","","","","","1.33","Fee Schedule","","","","","1.33","Fee Schedule","","","52","","1.33","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","86","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.93","70","","","Percent of Total Billed Charges","neg_dollar:$0.93","","52","","1.33","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% of Medicaid interim rate","1.00","75","","","Percent of Total Billed Charges","neg_dollar:$1","1.14","86","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.93","70","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.33","150","","","Percent of Total Billed Charges","neg_dollar:$2.06;150% of Medicaid interim rate","1.06","80","","","Percent of Total Billed Charges","neg_dollar:$1.06;Percent of Total Billed Charges","1.22","92","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.69","52","","","Percent of Total Billed Charges","neg_dollar:$0.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.33","Fee Schedule","","1.00","1.00",""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","","","00527-4591-13","NDC","250","RC","","Facility","Outpatient","30","ME","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","","52","","2.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.05","Fee Schedule","","1.00","2.00",""
"DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML PO SYRP","","","00536-1313-85","NDC","250","RC","","Facility","Outpatient","1","UN","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"POLYVINYL ALCOHOL 1.4 % OP SOLN","","","00536-1408-94","NDC","250","RC","","Facility","Outpatient","1","EA","16.40","16.40","","","","16.40","Fee Schedule","","","","","16.40","Fee Schedule","","","","","16.40","Fee Schedule","","","52","","16.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.10","86","","","Percent of Total Billed Charges","neg_dollar:$14.10","11.47","70","","","Percent of Total Billed Charges","neg_dollar:$11.47","","52","","16.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.63;102% of Medicaid interim rate","12.29","75","","","Percent of Total Billed Charges","neg_dollar:$12.29","14.10","86","","","Percent of Total Billed Charges","neg_dollar:$14.10","11.47","70","","","Percent of Total Billed Charges","neg_dollar:$11.47","9.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.34;103.5% of Medicaid interim rate","16.40","150","","","Percent of Total Billed Charges","neg_dollar:$25.35;150% of Medicaid interim rate","13.12","80","","","Percent of Total Billed Charges","neg_dollar:$13.12;Percent of Total Billed Charges","15.08","92","","","Percent of Total Billed Charges","neg_dollar:$15.08","8.52","52","","","Percent of Total Billed Charges","neg_dollar:$8.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","16.40","Fee Schedule","","8.00","16.00",""
"NICOTINE 14 MG/24HR TD PT24","","","00536-5895-88","NDC","250","RC","","Facility","Outpatient","1","EA","3.10","3.10","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","","","52","","3.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","","52","","3.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% of Medicaid interim rate","2.32","75","","","Percent of Total Billed Charges","neg_dollar:$2.32","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","1.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.76;103.5% of Medicaid interim rate","3.10","150","","","Percent of Total Billed Charges","neg_dollar:$4.79;150% of Medicaid interim rate","2.48","80","","","Percent of Total Billed Charges","neg_dollar:$2.48;Percent of Total Billed Charges","2.85","92","","","Percent of Total Billed Charges","neg_dollar:$2.85","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.10","Fee Schedule","","1.00","3.00",""
"NICOTINE 21 MG/24HR TD PT24","","","00536-5896-88","NDC","250","RC","","Facility","Outpatient","1","EA","3.10","3.10","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","","","","","3.10","Fee Schedule","","","52","","3.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","","52","","3.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.82;102% of Medicaid interim rate","2.32","75","","","Percent of Total Billed Charges","neg_dollar:$2.32","2.66","86","","","Percent of Total Billed Charges","neg_dollar:$2.66","2.17","70","","","Percent of Total Billed Charges","neg_dollar:$2.17","1.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.76;103.5% of Medicaid interim rate","3.10","150","","","Percent of Total Billed Charges","neg_dollar:$4.79;150% of Medicaid interim rate","2.48","80","","","Percent of Total Billed Charges","neg_dollar:$2.48;Percent of Total Billed Charges","2.85","92","","","Percent of Total Billed Charges","neg_dollar:$2.85","1.61","52","","","Percent of Total Billed Charges","neg_dollar:$1.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.10","Fee Schedule","","1.00","3.00",""
"AMILORIDE HCL 5 MG PO TABS","","","00574-0292-01","NDC","250","RC","","Facility","Outpatient","5","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"FERROUS GLUCONATE 324 (38 FE) MG PO TABS","","","00574-0508-11","NDC","637","RC","","Facility","Outpatient","324","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","101% of Medicare Fee Schedule","","","","1.15","Fee Schedule","","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FERROUS GLUCONATE 324 (38 FE) MG PO TABS","","","00574-0508-11","NDC","250","RC","","Facility","Outpatient","324","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","","52","","1.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.15","Fee Schedule","","1.00","1.00",""
"CHARCOAL ACTIVATED PO LIQD","","","00574-0521-74","NDC","250","RC","","Facility","Outpatient","1","EA","16.50","16.50","","","","16.50","Fee Schedule","","","","","16.50","Fee Schedule","","","","","16.50","Fee Schedule","","","52","","16.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.58","52","","","Percent of Total Billed Charges","neg_dollar:$8.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.58","52","","","Percent of Total Billed Charges","neg_dollar:$8.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.19","86","","","Percent of Total Billed Charges","neg_dollar:$14.19","11.54","70","","","Percent of Total Billed Charges","neg_dollar:$11.54","","52","","16.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.69;102% of Medicaid interim rate","12.37","75","","","Percent of Total Billed Charges","neg_dollar:$12.37","14.19","86","","","Percent of Total Billed Charges","neg_dollar:$14.19","11.54","70","","","Percent of Total Billed Charges","neg_dollar:$11.54","9.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.40;103.5% of Medicaid interim rate","16.50","150","","","Percent of Total Billed Charges","neg_dollar:$25.50;150% of Medicaid interim rate","13.20","80","","","Percent of Total Billed Charges","neg_dollar:$13.20;Percent of Total Billed Charges","15.18","92","","","Percent of Total Billed Charges","neg_dollar:$15.18","8.58","52","","","Percent of Total Billed Charges","neg_dollar:$8.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","16.50","Fee Schedule","","8.00","16.00",""
"BISACODYL 10 MG RE SUPP","","","00574-7050-12","NDC","250","RC","","Facility","Outpatient","10","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"LIDOCAINE 5 % EX PTCH","","","00591-3525-11","NDC","250","RC","","Facility","Outpatient","1","EA","4.60","4.60","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","","52","","4.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% of Medicaid interim rate","3.44","75","","","Percent of Total Billed Charges","neg_dollar:$3.44","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.62;103.5% of Medicaid interim rate","4.60","150","","","Percent of Total Billed Charges","neg_dollar:$7.11;150% of Medicaid interim rate","3.67","80","","","Percent of Total Billed Charges","neg_dollar:$3.67;Percent of Total Billed Charges","4.23","92","","","Percent of Total Billed Charges","neg_dollar:$4.23","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.60","Fee Schedule","","2.00","4.00",""
"TIOTROPIUM BROMIDE MONOHYDRATE 18 MCG IN CAPS","","","00597-0075-75","NDC","250","RC","","Facility","Outpatient","1","EA","122.10","122.10","","","","122.10","Fee Schedule","","","","","122.10","Fee Schedule","","","","","122.10","Fee Schedule","","","52","","122.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","63.49","52","","","Percent of Total Billed Charges","neg_dollar:$63.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","63.49","52","","","Percent of Total Billed Charges","neg_dollar:$63.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","105.00","86","","","Percent of Total Billed Charges","neg_dollar:$105","85.46","70","","","Percent of Total Billed Charges","neg_dollar:$85.46","","52","","122.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","71.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.73;102% of Medicaid interim rate","91.57","75","","","Percent of Total Billed Charges","neg_dollar:$91.57","105.00","86","","","Percent of Total Billed Charges","neg_dollar:$105","85.46","70","","","Percent of Total Billed Charges","neg_dollar:$85.46","69.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$69.59;103.5% of Medicaid interim rate","122.10","150","","","Percent of Total Billed Charges","neg_dollar:$188.77;150% of Medicaid interim rate","97.68","80","","","Percent of Total Billed Charges","neg_dollar:$97.68;Percent of Total Billed Charges","112.33","92","","","Percent of Total Billed Charges","neg_dollar:$112.33","63.49","52","","","Percent of Total Billed Charges","neg_dollar:$63.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","122.10","Fee Schedule","","63.00","122.00",""
"LIDOCAINE 5 % EX PTCH","","","00603-1880-16","NDC","637","RC","","Facility","Outpatient","5","EA","4.60","4.60","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","101% of Medicare Fee Schedule","","","","4.60","Fee Schedule","","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% of Medicaid interim rate","3.44","75","","","Percent of Total Billed Charges","neg_dollar:$3.44","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.62;103.5% of Medicaid interim rate","4.60","150","","","Percent of Total Billed Charges","neg_dollar:$7.11;150% of Medicaid interim rate","3.67","80","","","Percent of Total Billed Charges","neg_dollar:$3.67;Percent of Total Billed Charges","4.23","92","","","Percent of Total Billed Charges","neg_dollar:$4.23","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"LIDOCAINE 5 % EX PTCH","","","00603-1880-16","NDC","250","RC","","Facility","Outpatient","1","EA","4.60","4.60","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","","52","","4.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% of Medicaid interim rate","3.44","75","","","Percent of Total Billed Charges","neg_dollar:$3.44","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.62;103.5% of Medicaid interim rate","4.60","150","","","Percent of Total Billed Charges","neg_dollar:$7.11;150% of Medicaid interim rate","3.67","80","","","Percent of Total Billed Charges","neg_dollar:$3.67;Percent of Total Billed Charges","4.23","92","","","Percent of Total Billed Charges","neg_dollar:$4.23","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.60","Fee Schedule","","2.00","4.00",""
"DILTIAZEM HCL 25 MG/5ML IV SOLN","","","00641-6013-01","NDC","250","RC","","Facility","Outpatient","1","EA","91.63","91.63","","","","91.63","Fee Schedule","","","","","91.63","Fee Schedule","","","","","91.63","Fee Schedule","","","52","","91.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.64","52","","","Percent of Total Billed Charges","neg_dollar:$47.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.64","52","","","Percent of Total Billed Charges","neg_dollar:$47.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.80","86","","","Percent of Total Billed Charges","neg_dollar:$78.80","64.14","70","","","Percent of Total Billed Charges","neg_dollar:$64.14","","52","","91.63","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.83;102% of Medicaid interim rate","68.72","75","","","Percent of Total Billed Charges","neg_dollar:$68.72","78.80","86","","","Percent of Total Billed Charges","neg_dollar:$78.80","64.14","70","","","Percent of Total Billed Charges","neg_dollar:$64.14","52.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.23;103.5% of Medicaid interim rate","91.63","150","","","Percent of Total Billed Charges","neg_dollar:$141.66;150% of Medicaid interim rate","73.30","80","","","Percent of Total Billed Charges","neg_dollar:$73.30;Percent of Total Billed Charges","84.30","92","","","Percent of Total Billed Charges","neg_dollar:$84.30","47.64","52","","","Percent of Total Billed Charges","neg_dollar:$47.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","91.63","Fee Schedule","","47.00","91.00",""
"DILTIAZEM HCL 125 MG/25ML IV SOLN","","","00641-6015-10","NDC","250","RC","","Facility","Outpatient","1","UN","105.70","105.70","","","","105.70","Fee Schedule","","","","","105.70","Fee Schedule","","","","","105.70","Fee Schedule","","","52","","105.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","54.96","52","","","Percent of Total Billed Charges","neg_dollar:$54.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","54.96","52","","","Percent of Total Billed Charges","neg_dollar:$54.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","90.90","86","","","Percent of Total Billed Charges","neg_dollar:$90.90","73.99","70","","","Percent of Total Billed Charges","neg_dollar:$73.99","","52","","105.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","62.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$62.09;102% of Medicaid interim rate","79.27","75","","","Percent of Total Billed Charges","neg_dollar:$79.27","90.90","86","","","Percent of Total Billed Charges","neg_dollar:$90.90","73.99","70","","","Percent of Total Billed Charges","neg_dollar:$73.99","60.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$60.24;103.5% of Medicaid interim rate","105.70","150","","","Percent of Total Billed Charges","neg_dollar:$163.41;150% of Medicaid interim rate","84.56","80","","","Percent of Total Billed Charges","neg_dollar:$84.56;Percent of Total Billed Charges","97.24","92","","","Percent of Total Billed Charges","neg_dollar:$97.24","54.96","52","","","Percent of Total Billed Charges","neg_dollar:$54.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","105.70","Fee Schedule","","54.00","105.00",""
"PROMETHAZINE HCL 25 MG RE SUPP","","","00713-0526-12","NDC","250","RC","","Facility","Outpatient","25","ME","6.85","6.85","","","","6.85","Fee Schedule","","","","","6.85","Fee Schedule","","","","","6.85","Fee Schedule","","","52","","6.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.56","52","","","Percent of Total Billed Charges","neg_dollar:$3.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.56","52","","","Percent of Total Billed Charges","neg_dollar:$3.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.89","86","","","Percent of Total Billed Charges","neg_dollar:$5.89","4.79","70","","","Percent of Total Billed Charges","neg_dollar:$4.79","","52","","6.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","4.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.02;102% of Medicaid interim rate","5.13","75","","","Percent of Total Billed Charges","neg_dollar:$5.13","5.89","86","","","Percent of Total Billed Charges","neg_dollar:$5.89","4.79","70","","","Percent of Total Billed Charges","neg_dollar:$4.79","3.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.90;103.5% of Medicaid interim rate","6.85","150","","","Percent of Total Billed Charges","neg_dollar:$10.59;150% of Medicaid interim rate","5.48","80","","","Percent of Total Billed Charges","neg_dollar:$5.48;Percent of Total Billed Charges","6.30","92","","","Percent of Total Billed Charges","neg_dollar:$6.30","3.56","52","","","Percent of Total Billed Charges","neg_dollar:$3.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","6.85","Fee Schedule","","3.00","6.00",""
"NYSTATIN 100000 UNIT/GM EX CREA","","","00713-0678-31","NDC","250","RC","","Facility","Outpatient","1","EA","32.50","32.50","","","","32.50","Fee Schedule","","","","","32.50","Fee Schedule","","","","","32.50","Fee Schedule","","","52","","32.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.95","86","","","Percent of Total Billed Charges","neg_dollar:$27.95","22.75","70","","","Percent of Total Billed Charges","neg_dollar:$22.75","","52","","32.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","19.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.09;102% of Medicaid interim rate","24.37","75","","","Percent of Total Billed Charges","neg_dollar:$24.37","27.95","86","","","Percent of Total Billed Charges","neg_dollar:$27.95","22.75","70","","","Percent of Total Billed Charges","neg_dollar:$22.75","18.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.52;103.5% of Medicaid interim rate","32.50","150","","","Percent of Total Billed Charges","neg_dollar:$50.24;150% of Medicaid interim rate","26.00","80","","","Percent of Total Billed Charges","neg_dollar:$26;Percent of Total Billed Charges","29.90","92","","","Percent of Total Billed Charges","neg_dollar:$29.90","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","32.50","Fee Schedule","","16.00","32.00",""
"AMOXICILLIN 250 MG PO CAPS","","","00781-2020-01","NDC","250","RC","","Facility","Outpatient","250","ME","0.65","0.65","","","","0.65","Fee Schedule","","","","","0.65","Fee Schedule","","","","","0.65","Fee Schedule","","","52","","0.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","","52","","0.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.38;102% of Medicaid interim rate","0.48","75","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","0.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.37;103.5% of Medicaid interim rate","0.65","150","","","Percent of Total Billed Charges","neg_dollar:$1;150% of Medicaid interim rate","0.52","80","","","Percent of Total Billed Charges","neg_dollar:$0.52;Percent of Total Billed Charges","0.59","92","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.65","Fee Schedule","","1.00","1.00",""
"AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR","","","00781-6139-57","NDC","250","RC","","Facility","Outpatient","1","EA","35.25","35.25","","","","35.25","Fee Schedule","","","","","35.25","Fee Schedule","","","","","35.25","Fee Schedule","","","52","","35.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","18.33","52","","","Percent of Total Billed Charges","neg_dollar:$18.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.33","52","","","Percent of Total Billed Charges","neg_dollar:$18.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.31","86","","","Percent of Total Billed Charges","neg_dollar:$30.31","24.67","70","","","Percent of Total Billed Charges","neg_dollar:$24.67","","52","","35.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","20.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.70;102% of Medicaid interim rate","26.43","75","","","Percent of Total Billed Charges","neg_dollar:$26.43","30.31","86","","","Percent of Total Billed Charges","neg_dollar:$30.31","24.67","70","","","Percent of Total Billed Charges","neg_dollar:$24.67","20.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.09;103.5% of Medicaid interim rate","35.25","150","","","Percent of Total Billed Charges","neg_dollar:$54.49;150% of Medicaid interim rate","28.20","80","","","Percent of Total Billed Charges","neg_dollar:$28.20;Percent of Total Billed Charges","32.43","92","","","Percent of Total Billed Charges","neg_dollar:$32.43","18.33","52","","","Percent of Total Billed Charges","neg_dollar:$18.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","35.25","Fee Schedule","","18.00","35.00",""
"AMOXICILLIN 400 MG/5ML PO SUSR","","","00781-6157-57","NDC","250","RC","","Facility","Outpatient","1","UN","15.80","15.80","","","","15.80","Fee Schedule","","","","","15.80","Fee Schedule","","","","","15.80","Fee Schedule","","","52","","15.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.21","52","","","Percent of Total Billed Charges","neg_dollar:$8.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.21","52","","","Percent of Total Billed Charges","neg_dollar:$8.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.58","86","","","Percent of Total Billed Charges","neg_dollar:$13.58","11.06","70","","","Percent of Total Billed Charges","neg_dollar:$11.06","","52","","15.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.28;102% of Medicaid interim rate","11.85","75","","","Percent of Total Billed Charges","neg_dollar:$11.85","13.58","86","","","Percent of Total Billed Charges","neg_dollar:$13.58","11.06","70","","","Percent of Total Billed Charges","neg_dollar:$11.06","9.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$9;103.5% of Medicaid interim rate","15.80","150","","","Percent of Total Billed Charges","neg_dollar:$24.42;150% of Medicaid interim rate","12.64","80","","","Percent of Total Billed Charges","neg_dollar:$12.64;Percent of Total Billed Charges","14.53","92","","","Percent of Total Billed Charges","neg_dollar:$14.53","8.21","52","","","Percent of Total Billed Charges","neg_dollar:$8.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","15.80","Fee Schedule","","8.00","15.00",""
"WARFARIN SODIUM 5 MG PO TABS","","","00832-1216-89","NDC","250","RC","","Facility","Outpatient","5","ME","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","","52","","1.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.31;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.50","Fee Schedule","","1.00","1.00",""
"ASCORBIC ACID 500 MG PO TABS","","","00904-0523-61","NDC","250","RC","","Facility","Outpatient","500","ME","0.55","0.55","","","","0.55","Fee Schedule","","","","","0.55","Fee Schedule","","","","","0.55","Fee Schedule","","","52","","0.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","","52","","0.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% of Medicaid interim rate","0.41","75","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.31;103.5% of Medicaid interim rate","0.55","150","","","Percent of Total Billed Charges","neg_dollar:$0.85;150% of Medicaid interim rate","0.44","80","","","Percent of Total Billed Charges","neg_dollar:$0.44;Percent of Total Billed Charges","0.50","92","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.55","Fee Schedule","","1.00","1.00",""
"THERA PO TABS","","","00904-0530-61","NDC","250","RC","","Facility","Outpatient","1","EA","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"SODIUM CHLORIDE (SALINE) 0.65% NASAL SPRAY WRAPPER","","","00904-3865-75","NDC","250","RC","","Facility","Outpatient","1","EA","11.55","11.55","","","","11.55","Fee Schedule","","","","","11.55","Fee Schedule","","","","","11.55","Fee Schedule","","","52","","11.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","52","","","Percent of Total Billed Charges","neg_dollar:$6;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","52","","","Percent of Total Billed Charges","neg_dollar:$6;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.93","86","","","Percent of Total Billed Charges","neg_dollar:$9.93","8.08","70","","","Percent of Total Billed Charges","neg_dollar:$8.08","","52","","11.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.78;102% of Medicaid interim rate","8.66","75","","","Percent of Total Billed Charges","neg_dollar:$8.66","9.93","86","","","Percent of Total Billed Charges","neg_dollar:$9.93","8.08","70","","","Percent of Total Billed Charges","neg_dollar:$8.08","6.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.58;103.5% of Medicaid interim rate","11.55","150","","","Percent of Total Billed Charges","neg_dollar:$17.85;150% of Medicaid interim rate","9.24","80","","","Percent of Total Billed Charges","neg_dollar:$9.24;Percent of Total Billed Charges","10.62","92","","","Percent of Total Billed Charges","neg_dollar:$10.62","6.00","52","","","Percent of Total Billed Charges","neg_dollar:$6;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","11.55","Fee Schedule","","6.00","11.00",""
"IBUPROFEN 400 MG PO TABS","","","00904-5853-61","NDC","250","RC","","Facility","Outpatient","400","ME","0.54","0.54","","","","0.54","Fee Schedule","","","","","0.54","Fee Schedule","","","","","0.54","Fee Schedule","","","52","","0.54","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","86","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.37","70","","","Percent of Total Billed Charges","neg_dollar:$0.37","","52","","0.54","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.31;102% of Medicaid interim rate","0.40","75","","","Percent of Total Billed Charges","neg_dollar:$0.40","0.46","86","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.37","70","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.30;103.5% of Medicaid interim rate","0.54","150","","","Percent of Total Billed Charges","neg_dollar:$0.83;150% of Medicaid interim rate","0.43","80","","","Percent of Total Billed Charges","neg_dollar:$0.43;Percent of Total Billed Charges","0.49","92","","","Percent of Total Billed Charges","neg_dollar:$0.49","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.54","Fee Schedule","","1.00","1.00",""
"IBUPROFEN 400 MG PO TABS","","","00904-5853-61","NDC","637","RC","","Facility","Outpatient","400","ME","0.60","0.60","","","","0.60","Fee Schedule","","","","","0.60","Fee Schedule","101% of Medicare Fee Schedule","","","","0.60","Fee Schedule","","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% of Medicaid interim rate","0.44","75","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.34;103.5% of Medicaid interim rate","0.60","150","","","Percent of Total Billed Charges","neg_dollar:$0.92;150% of Medicaid interim rate","0.48","80","","","Percent of Total Billed Charges","neg_dollar:$0.48;Percent of Total Billed Charges","0.55","92","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CITALOPRAM HYDROBROMIDE 20 MG PO TABS","","","00904-6085-61","NDC","250","RC","","Facility","Outpatient","20","ME","0.95","0.95","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","","52","","0.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.71","75","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;103.5% of Medicaid interim rate","0.95","150","","","Percent of Total Billed Charges","neg_dollar:$1.46;150% of Medicaid interim rate","0.76","80","","","Percent of Total Billed Charges","neg_dollar:$0.76;Percent of Total Billed Charges","0.87","92","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.95","Fee Schedule","","1.00","1.00",""
"CARVEDILOL 3.125 MG PO TABS","","","00904-6300-61","NDC","250","RC","","Facility","Outpatient","1","EA","0.60","0.60","","","","0.60","Fee Schedule","","","","","0.60","Fee Schedule","","","","","0.60","Fee Schedule","","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","","52","","0.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% of Medicaid interim rate","0.44","75","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.34;103.5% of Medicaid interim rate","0.60","150","","","Percent of Total Billed Charges","neg_dollar:$0.92;150% of Medicaid interim rate","0.48","80","","","Percent of Total Billed Charges","neg_dollar:$0.48;Percent of Total Billed Charges","0.55","92","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.60","Fee Schedule","","1.00","1.00",""
"CARVEDILOL 25 MG PO TABS","","","00904-6303-61","NDC","250","RC","","Facility","Outpatient","25","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"METOPROLOL SUCCINATE ER 25 MG PO TB24","","","00904-6322-61","NDC","250","RC","","Facility","Outpatient","25","ME","1.61","1.61","","","","1.61","Fee Schedule","","","","","1.61","Fee Schedule","","","","","1.61","Fee Schedule","","","52","","1.61","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.12","70","","","Percent of Total Billed Charges","neg_dollar:$1.12","","52","","1.61","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.38","86","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.12","70","","","Percent of Total Billed Charges","neg_dollar:$1.12","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.61","150","","","Percent of Total Billed Charges","neg_dollar:$2.49;150% of Medicaid interim rate","1.29","80","","","Percent of Total Billed Charges","neg_dollar:$1.29;Percent of Total Billed Charges","1.48","92","","","Percent of Total Billed Charges","neg_dollar:$1.48","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.61","Fee Schedule","","1.00","1.00",""
"METOPROLOL SUCCINATE ER 25 MG PO TB24","","","00904-6322-61","NDC","637","RC","","Facility","Outpatient","25","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","101% of Medicare Fee Schedule","","","","1.55","Fee Schedule","","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METOPROLOL SUCCINATE ER 25 MG PO TB24","","","00904-6322-61","NDC","637","RC","","Facility","Outpatient","25","ME","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","101% of Medicare Fee Schedule","","","","2.05","Fee Schedule","","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"LEVOFLOXACIN 500 MG PO TABS","","","00904-6352-61","NDC","250","RC","","Facility","Outpatient","500","ME","0.92","0.92","","","","0.92","Fee Schedule","","","","","0.92","Fee Schedule","","","","","0.92","Fee Schedule","","","52","","0.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","86","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.64","70","","","Percent of Total Billed Charges","neg_dollar:$0.64","","52","","0.92","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% of Medicaid interim rate","0.69","75","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.79","86","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.64","70","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;103.5% of Medicaid interim rate","0.92","150","","","Percent of Total Billed Charges","neg_dollar:$1.43;150% of Medicaid interim rate","0.74","80","","","Percent of Total Billed Charges","neg_dollar:$0.74;Percent of Total Billed Charges","0.85","92","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.92","Fee Schedule","","1.00","1.00",""
"AMLODIPINE BESYLATE 5 MG PO TABS","","","00904-6370-61","NDC","250","RC","","Facility","Outpatient","5","ME","0.92","0.92","","","","0.92","Fee Schedule","","","","","0.92","Fee Schedule","","","","","0.92","Fee Schedule","","","52","","0.92","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","86","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","","52","","0.92","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% of Medicaid interim rate","0.69","75","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.79","86","","","Percent of Total Billed Charges","neg_dollar:$0.79","0.65","70","","","Percent of Total Billed Charges","neg_dollar:$0.65","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;103.5% of Medicaid interim rate","0.92","150","","","Percent of Total Billed Charges","neg_dollar:$1.43;150% of Medicaid interim rate","0.74","80","","","Percent of Total Billed Charges","neg_dollar:$0.74;Percent of Total Billed Charges","0.85","92","","","Percent of Total Billed Charges","neg_dollar:$0.85","0.48","52","","","Percent of Total Billed Charges","neg_dollar:$0.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.92","Fee Schedule","","1.00","1.00",""
"AMLODIPINE BESYLATE 5 MG PO TABS","","","00904-6370-61","NDC","637","RC","","Facility","Outpatient","5","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"AMLODIPINE BESYLATE 5 MG PO TABS","","","00904-6370-61","NDC","637","RC","","Facility","Outpatient","5","ME","0.60","0.60","","","","0.60","Fee Schedule","","","","","0.60","Fee Schedule","101% of Medicare Fee Schedule","","","","0.60","Fee Schedule","","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% of Medicaid interim rate","0.44","75","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.34;103.5% of Medicaid interim rate","0.60","150","","","Percent of Total Billed Charges","neg_dollar:$0.92;150% of Medicaid interim rate","0.48","80","","","Percent of Total Billed Charges","neg_dollar:$0.48;Percent of Total Billed Charges","0.55","92","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ROPINIROLE HCL 0.25 MG PO TABS","","","00904-6373-61","NDC","250","RC","","Facility","Outpatient","1","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"ROPINIROLE HCL 1 MG PO TABS","","","00904-6374-61","NDC","250","RC","","Facility","Outpatient","1","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"BISACODYL 5 MG PO TBEC","","","00904-6407-61","NDC","250","RC","","Facility","Outpatient","5","ME","0.28","0.28","","","","0.28","Fee Schedule","","","","","0.28","Fee Schedule","","","","","0.28","Fee Schedule","","","52","","0.28","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.24","86","","","Percent of Total Billed Charges","neg_dollar:$0.24","0.20","70","","","Percent of Total Billed Charges","neg_dollar:$0.20","","52","","0.28","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.16;102% of Medicaid interim rate","0.21","75","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.24","86","","","Percent of Total Billed Charges","neg_dollar:$0.24","0.20","70","","","Percent of Total Billed Charges","neg_dollar:$0.20","0.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.16;103.5% of Medicaid interim rate","0.28","150","","","Percent of Total Billed Charges","neg_dollar:$0.44;150% of Medicaid interim rate","0.22","80","","","Percent of Total Billed Charges","neg_dollar:$0.22;Percent of Total Billed Charges","0.26","92","","","Percent of Total Billed Charges","neg_dollar:$0.26","0.14","52","","","Percent of Total Billed Charges","neg_dollar:$0.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.28","Fee Schedule","","1.00","1.00",""
"QUETIAPINE FUMARATE 25 MG PO TABS","","","00904-6638-61","NDC","250","RC","","Facility","Outpatient","25","ME","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","","52","","0.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% of Medicaid interim rate","0.63","75","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.31;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.85","Fee Schedule","","1.00","1.00",""
"GABAPENTIN 400 MG PO CAPS","","","00904-6667-61","NDC","250","RC","","Facility","Outpatient","400","ME","0.75","0.75","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","","","52","","0.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","","52","","0.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% of Medicaid interim rate","0.56","75","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;103.5% of Medicaid interim rate","0.75","150","","","Percent of Total Billed Charges","neg_dollar:$1.15;150% of Medicaid interim rate","0.60","80","","","Percent of Total Billed Charges","neg_dollar:$0.60;Percent of Total Billed Charges","0.69","92","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.75","Fee Schedule","","1.00","1.00",""
"CETIRIZINE HCL 10 MG PO TABS","","","00904-6717-61","NDC","637","RC","","Facility","Outpatient","10","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CETIRIZINE HCL 10 MG PO TABS","","","00904-6717-61","NDC","250","RC","","Facility","Outpatient","10","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"ACETAMINOPHEN 500 MG PO TABS","","","00904-6730-61","NDC","250","RC","","Facility","Outpatient","500","ME","0.25","0.25","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","","52","","0.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% of Medicaid interim rate","0.18","75","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.25","150","","","Percent of Total Billed Charges","neg_dollar:$0.39;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.25","Fee Schedule","","1.00","1.00",""
"ACETAMINOPHEN 500 MG PO TABS","","","00904-6730-61","NDC","637","RC","","Facility","Outpatient","500","ME","0.25","0.25","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","101% of Medicare Fee Schedule","","","","0.25","Fee Schedule","","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% of Medicaid interim rate","0.18","75","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.25","150","","","Percent of Total Billed Charges","neg_dollar:$0.38;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ACETAMINOPHEN 325 MG PO TABS","","","00904-6773-61","NDC","637","RC","","Facility","Outpatient","325","ME","0.25","0.25","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","101% of Medicare Fee Schedule","","","","0.25","Fee Schedule","","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% of Medicaid interim rate","0.18","75","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.25","150","","","Percent of Total Billed Charges","neg_dollar:$0.38;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ACETAMINOPHEN 325 MG PO TABS","","","00904-6773-61","NDC","250","RC","","Facility","Outpatient","325","ME","0.25","0.25","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","","","","","0.25","Fee Schedule","","","52","","0.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","","52","","0.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;102% of Medicaid interim rate","0.18","75","","","Percent of Total Billed Charges","neg_dollar:$0.18","0.21","86","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","70","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.14;103.5% of Medicaid interim rate","0.25","150","","","Percent of Total Billed Charges","neg_dollar:$0.38;150% of Medicaid interim rate","0.20","80","","","Percent of Total Billed Charges","neg_dollar:$0.20;Percent of Total Billed Charges","0.23","92","","","Percent of Total Billed Charges","neg_dollar:$0.23","0.13","52","","","Percent of Total Billed Charges","neg_dollar:$0.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.25","Fee Schedule","","1.00","1.00",""
"ASPIRIN 81 MG PO TBEC","","","00904-6783-70","NDC","250","RC","","Facility","Outpatient","81","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","","52","","0.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.50","Fee Schedule","","1.00","1.00",""
"ASPIRIN LOW DOSE 81 MG PO CHEW","","","00904-6794-89","NDC","250","RC","","Facility","Outpatient","81","ME","0.14","0.14","","","","0.14","Fee Schedule","","","","","0.14","Fee Schedule","","","","","0.14","Fee Schedule","","","52","","0.14","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.12","86","","","Percent of Total Billed Charges","neg_dollar:$0.12","0.09","70","","","Percent of Total Billed Charges","neg_dollar:$0.09","","52","","0.14","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.08;102% of Medicaid interim rate","0.10","75","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.12","86","","","Percent of Total Billed Charges","neg_dollar:$0.12","0.09","70","","","Percent of Total Billed Charges","neg_dollar:$0.09","0.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.08;103.5% of Medicaid interim rate","0.14","150","","","Percent of Total Billed Charges","neg_dollar:$0.22;150% of Medicaid interim rate","0.11","80","","","Percent of Total Billed Charges","neg_dollar:$0.11;Percent of Total Billed Charges","0.13","92","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.14","Fee Schedule","","1.00","1.00",""
"LISINOPRIL 5 MG PO TABS","","","00904-6797-61","NDC","250","RC","","Facility","Outpatient","5","ME","0.55","0.55","","","","0.55","Fee Schedule","","","","","0.55","Fee Schedule","","","","","0.55","Fee Schedule","","","52","","0.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","","52","","0.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% of Medicaid interim rate","0.41","75","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.47","86","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","70","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.31;103.5% of Medicaid interim rate","0.55","150","","","Percent of Total Billed Charges","neg_dollar:$0.85;150% of Medicaid interim rate","0.44","80","","","Percent of Total Billed Charges","neg_dollar:$0.44;Percent of Total Billed Charges","0.51","92","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.28","52","","","Percent of Total Billed Charges","neg_dollar:$0.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.55","Fee Schedule","","1.00","1.00",""
"LISINOPRIL 20 MG PO TABS","","","00904-6799-61","NDC","637","RC","","Facility","Outpatient","20","ME","0.60","0.60","","","","0.60","Fee Schedule","","","","","0.60","Fee Schedule","101% of Medicare Fee Schedule","","","","0.60","Fee Schedule","","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% of Medicaid interim rate","0.44","75","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.51","86","","","Percent of Total Billed Charges","neg_dollar:$0.51","0.42","70","","","Percent of Total Billed Charges","neg_dollar:$0.42","0.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.34;103.5% of Medicaid interim rate","0.60","150","","","Percent of Total Billed Charges","neg_dollar:$0.92;150% of Medicaid interim rate","0.48","80","","","Percent of Total Billed Charges","neg_dollar:$0.48;Percent of Total Billed Charges","0.55","92","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.31","52","","","Percent of Total Billed Charges","neg_dollar:$0.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LISINOPRIL 20 MG PO TABS","","","00904-6799-61","NDC","250","RC","","Facility","Outpatient","20","ME","0.77","0.77","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","","52","","0.77","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.58","75","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.77","150","","","Percent of Total Billed Charges","neg_dollar:$1.19;150% of Medicaid interim rate","0.62","80","","","Percent of Total Billed Charges","neg_dollar:$0.62;Percent of Total Billed Charges","0.71","92","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.77","Fee Schedule","","1.00","1.00",""
"TRAZODONE HCL 50 MG PO TABS","","","00904-6868-61","NDC","250","RC","","Facility","Outpatient","50","ME","0.65","0.65","","","","0.65","Fee Schedule","","","","","0.65","Fee Schedule","","","","","0.65","Fee Schedule","","","52","","0.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","","52","","0.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.38;102% of Medicaid interim rate","0.48","75","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","0.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.37;103.5% of Medicaid interim rate","0.65","150","","","Percent of Total Billed Charges","neg_dollar:$1;150% of Medicaid interim rate","0.52","80","","","Percent of Total Billed Charges","neg_dollar:$0.52;Percent of Total Billed Charges","0.59","92","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.65","Fee Schedule","","1.00","1.00",""
"CHLORTHALIDONE 25 MG PO TABS","","","00904-6900-04","NDC","250","RC","","Facility","Outpatient","25","ME","3.40","3.40","","","","3.40","Fee Schedule","","","","","3.40","Fee Schedule","","","","","3.40","Fee Schedule","","","52","","3.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.92","86","","","Percent of Total Billed Charges","neg_dollar:$2.92","2.38","70","","","Percent of Total Billed Charges","neg_dollar:$2.38","","52","","3.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.99;102% of Medicaid interim rate","2.55","75","","","Percent of Total Billed Charges","neg_dollar:$2.55","2.92","86","","","Percent of Total Billed Charges","neg_dollar:$2.92","2.38","70","","","Percent of Total Billed Charges","neg_dollar:$2.38","1.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.93;103.5% of Medicaid interim rate","3.40","150","","","Percent of Total Billed Charges","neg_dollar:$5.25;150% of Medicaid interim rate","2.72","80","","","Percent of Total Billed Charges","neg_dollar:$2.72;Percent of Total Billed Charges","3.12","92","","","Percent of Total Billed Charges","neg_dollar:$3.12","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.40","Fee Schedule","","1.00","3.00",""
"POLYETHYLENE GLYCOL 3350 17 G PO PACK","","","00904-6931-86","NDC","250","RC","","Facility","Outpatient","1","EA","2.85","2.85","","","","2.85","Fee Schedule","","","","","2.85","Fee Schedule","","","","","2.85","Fee Schedule","","","52","","2.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.48","52","","","Percent of Total Billed Charges","neg_dollar:$1.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.48","52","","","Percent of Total Billed Charges","neg_dollar:$1.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.45","86","","","Percent of Total Billed Charges","neg_dollar:$2.45","1.99","70","","","Percent of Total Billed Charges","neg_dollar:$1.99","","52","","2.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.67;102% of Medicaid interim rate","2.13","75","","","Percent of Total Billed Charges","neg_dollar:$2.13","2.45","86","","","Percent of Total Billed Charges","neg_dollar:$2.45","1.99","70","","","Percent of Total Billed Charges","neg_dollar:$1.99","1.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.62;103.5% of Medicaid interim rate","2.85","150","","","Percent of Total Billed Charges","neg_dollar:$4.40;150% of Medicaid interim rate","2.28","80","","","Percent of Total Billed Charges","neg_dollar:$2.28;Percent of Total Billed Charges","2.62","92","","","Percent of Total Billed Charges","neg_dollar:$2.62","1.48","52","","","Percent of Total Billed Charges","neg_dollar:$1.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.85","Fee Schedule","","1.00","2.00",""
"BACITRACIN OINTMENT WRAPPER","","","00904-7023-67","NDC","250","RC","","Facility","Outpatient","500","UN","5.96","5.96","","","","5.96","Fee Schedule","","","","","5.96","Fee Schedule","","","","","5.96","Fee Schedule","","","52","","5.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.10","52","","","Percent of Total Billed Charges","neg_dollar:$3.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.10","52","","","Percent of Total Billed Charges","neg_dollar:$3.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.13","86","","","Percent of Total Billed Charges","neg_dollar:$5.13","4.17","70","","","Percent of Total Billed Charges","neg_dollar:$4.17","","52","","5.96","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.50;102% of Medicaid interim rate","4.47","75","","","Percent of Total Billed Charges","neg_dollar:$4.47","5.13","86","","","Percent of Total Billed Charges","neg_dollar:$5.13","4.17","70","","","Percent of Total Billed Charges","neg_dollar:$4.17","3.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.40;103.5% of Medicaid interim rate","5.96","150","","","Percent of Total Billed Charges","neg_dollar:$9.22;150% of Medicaid interim rate","4.77","80","","","Percent of Total Billed Charges","neg_dollar:$4.77;Percent of Total Billed Charges","5.48","92","","","Percent of Total Billed Charges","neg_dollar:$5.48","3.10","52","","","Percent of Total Billed Charges","neg_dollar:$3.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.96","Fee Schedule","","3.00","5.00",""
"DULOXETINE HCL 30 MG PO CPEP","","","00904-7044-61","NDC","637","RC","","Facility","Outpatient","30","ME","2.22","2.22","","","","2.22","Fee Schedule","","","","","2.22","Fee Schedule","101% of Medicare Fee Schedule","","","","2.22","Fee Schedule","","1.15","52","","","Percent of Total Billed Charges","neg_dollar:$1.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.91","86","","","Percent of Total Billed Charges","neg_dollar:$1.91","1.55","70","","","Percent of Total Billed Charges","neg_dollar:$1.55","1.15","52","","","Percent of Total Billed Charges","neg_dollar:$1.15;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.30;102% of Medicaid interim rate","1.66","75","","","Percent of Total Billed Charges","neg_dollar:$1.66","1.91","86","","","Percent of Total Billed Charges","neg_dollar:$1.91","1.55","70","","","Percent of Total Billed Charges","neg_dollar:$1.55","1.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.26;103.5% of Medicaid interim rate","2.22","150","","","Percent of Total Billed Charges","neg_dollar:$3.43;150% of Medicaid interim rate","1.78","80","","","Percent of Total Billed Charges","neg_dollar:$1.78;Percent of Total Billed Charges","2.04","92","","","Percent of Total Billed Charges","neg_dollar:$2.04","1.15","52","","","Percent of Total Billed Charges","neg_dollar:$1.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.15","52","","","Percent of Total Billed Charges","neg_dollar:$1.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"DULOXETINE HCL 30 MG PO CPEP","","","00904-7044-61","NDC","250","RC","","Facility","Outpatient","30","ME","2.35","2.35","","","","2.35","Fee Schedule","","","","","2.35","Fee Schedule","","","","","2.35","Fee Schedule","","","52","","2.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.02","86","","","Percent of Total Billed Charges","neg_dollar:$2.02","1.65","70","","","Percent of Total Billed Charges","neg_dollar:$1.65","","52","","2.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.38;102% of Medicaid interim rate","1.76","75","","","Percent of Total Billed Charges","neg_dollar:$1.76","2.02","86","","","Percent of Total Billed Charges","neg_dollar:$2.02","1.65","70","","","Percent of Total Billed Charges","neg_dollar:$1.65","1.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.34;103.5% of Medicaid interim rate","2.35","150","","","Percent of Total Billed Charges","neg_dollar:$3.64;150% of Medicaid interim rate","1.88","80","","","Percent of Total Billed Charges","neg_dollar:$1.88;Percent of Total Billed Charges","2.16","92","","","Percent of Total Billed Charges","neg_dollar:$2.16","1.22","52","","","Percent of Total Billed Charges","neg_dollar:$1.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.35","Fee Schedule","","1.00","2.00",""
"CIPROFLOXACIN HCL 500 MG PO TABS","","","00904-7083-61","NDC","250","RC","","Facility","Outpatient","500","ME","1.01","1.01","","","","1.01","Fee Schedule","","","","","1.01","Fee Schedule","","","","","1.01","Fee Schedule","","","52","","1.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","86","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","70","","","Percent of Total Billed Charges","neg_dollar:$0.71","","52","","1.01","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% of Medicaid interim rate","0.76","75","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.87","86","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","70","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.01","150","","","Percent of Total Billed Charges","neg_dollar:$1.57;150% of Medicaid interim rate","0.81","80","","","Percent of Total Billed Charges","neg_dollar:$0.81;Percent of Total Billed Charges","0.93","92","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.01","Fee Schedule","","1.00","1.00",""
"BUPROPION HCL ER (XL) 150 MG PO TB24","","","00904-7084-04","NDC","250","RC","","Facility","Outpatient","1","EA","2.26","2.26","","","","2.26","Fee Schedule","","","","","2.26","Fee Schedule","","","","","2.26","Fee Schedule","","","52","","2.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.94","86","","","Percent of Total Billed Charges","neg_dollar:$1.94","1.58","70","","","Percent of Total Billed Charges","neg_dollar:$1.58","","52","","2.26","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.33;102% of Medicaid interim rate","1.69","75","","","Percent of Total Billed Charges","neg_dollar:$1.69","1.94","86","","","Percent of Total Billed Charges","neg_dollar:$1.94","1.58","70","","","Percent of Total Billed Charges","neg_dollar:$1.58","1.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.29;103.5% of Medicaid interim rate","2.26","150","","","Percent of Total Billed Charges","neg_dollar:$3.50;150% of Medicaid interim rate","1.81","80","","","Percent of Total Billed Charges","neg_dollar:$1.81;Percent of Total Billed Charges","2.08","92","","","Percent of Total Billed Charges","neg_dollar:$2.08","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.26","Fee Schedule","","1.00","2.00",""
"METRONIDAZOLE 500 MG PO TABS","","","00904-7126-61","NDC","250","RC","","Facility","Outpatient","500","ME","1.85","1.85","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","","52","","1.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;103.5% of Medicaid interim rate","1.85","150","","","Percent of Total Billed Charges","neg_dollar:$2.86;150% of Medicaid interim rate","1.48","80","","","Percent of Total Billed Charges","neg_dollar:$1.48;Percent of Total Billed Charges","1.70","92","","","Percent of Total Billed Charges","neg_dollar:$1.70","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.85","Fee Schedule","","1.00","1.00",""
"FUROSEMIDE 40 MG PO TABS","","","00904-7178-61","NDC","250","RC","","Facility","Outpatient","40","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"DOCUSATE SODIUM 100 MG PO CAPS","","","00904-7183-61","NDC","250","RC","","Facility","Outpatient","100","ME","0.65","0.65","","","","0.65","Fee Schedule","","","","","0.65","Fee Schedule","","","","","0.65","Fee Schedule","","","52","","0.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","86","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","","52","","0.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.38;102% of Medicaid interim rate","0.49","75","","","Percent of Total Billed Charges","neg_dollar:$0.49","0.56","86","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","0.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.37;103.5% of Medicaid interim rate","0.65","150","","","Percent of Total Billed Charges","neg_dollar:$1.01;150% of Medicaid interim rate","0.52","80","","","Percent of Total Billed Charges","neg_dollar:$0.52;Percent of Total Billed Charges","0.60","92","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.34","52","","","Percent of Total Billed Charges","neg_dollar:$0.34;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.65","Fee Schedule","","1.00","1.00",""
"FAMOTIDINE 20 MG PO TABS","","","00904-7193-61","NDC","250","RC","","Facility","Outpatient","20","ME","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","","52","","0.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% of Medicaid interim rate","0.63","75","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.31;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.85","Fee Schedule","","1.00","1.00",""
"DIPHENHYDRAMINE HCL 25 MG PO CAPS","","","00904-7237-61","NDC","250","RC","","Facility","Outpatient","25","ME","0.89","0.89","","","","0.89","Fee Schedule","","","","","0.89","Fee Schedule","","","","","0.89","Fee Schedule","","","52","","0.89","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","70","","","Percent of Total Billed Charges","neg_dollar:$0.62","","52","","0.89","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% of Medicaid interim rate","0.67","75","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","70","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.89","150","","","Percent of Total Billed Charges","neg_dollar:$1.38;150% of Medicaid interim rate","0.71","80","","","Percent of Total Billed Charges","neg_dollar:$0.71;Percent of Total Billed Charges","0.82","92","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.89","Fee Schedule","","1.00","1.00",""
"CIPROFLOXACIN HCL 500 MG PO TABS","","","00904-7243-61","NDC","250","RC","","Facility","Outpatient","500","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"SENNOSIDES 8.6 MG PO TABS","","","00904-7252-61","NDC","250","RC","","Facility","Outpatient","1","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"CARVEDILOL 3.125 MG PO TABS","","","00904-7305-61","NDC","250","RC","","Facility","Outpatient","1","EA","0.62","0.62","","","","0.62","Fee Schedule","","","","","0.62","Fee Schedule","","","","","0.62","Fee Schedule","","","52","","0.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","86","","","Percent of Total Billed Charges","neg_dollar:$0.53","0.43","70","","","Percent of Total Billed Charges","neg_dollar:$0.43","","52","","0.62","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.36;102% of Medicaid interim rate","0.46","75","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.53","86","","","Percent of Total Billed Charges","neg_dollar:$0.53","0.43","70","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.35;103.5% of Medicaid interim rate","0.62","150","","","Percent of Total Billed Charges","neg_dollar:$0.96;150% of Medicaid interim rate","0.50","80","","","Percent of Total Billed Charges","neg_dollar:$0.50;Percent of Total Billed Charges","0.57","92","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.62","Fee Schedule","","1.00","1.00",""
"FLUOXETINE HCL 20 MG PO CAPS","","","00904-7346-61","NDC","250","RC","","Facility","Outpatient","20","ME","0.52","0.52","","","","0.52","Fee Schedule","","","","","0.52","Fee Schedule","","","","","0.52","Fee Schedule","","","52","","0.52","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","86","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.36","70","","","Percent of Total Billed Charges","neg_dollar:$0.36","","52","","0.52","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.30;102% of Medicaid interim rate","0.39","75","","","Percent of Total Billed Charges","neg_dollar:$0.39","0.44","86","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.36","70","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;103.5% of Medicaid interim rate","0.52","150","","","Percent of Total Billed Charges","neg_dollar:$0.80;150% of Medicaid interim rate","0.41","80","","","Percent of Total Billed Charges","neg_dollar:$0.41;Percent of Total Billed Charges","0.47","92","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.52","Fee Schedule","","1.00","1.00",""
"FERROUS SULFATE 325 (65 FE) MG PO TABS","","","00904-7591-61","NDC","250","RC","","Facility","Outpatient","325","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"IBUPROFEN 200 MG PO TABS","","","00904-7914-61","NDC","250","RC","","Facility","Outpatient","200","ME","1.03","1.03","","","","1.03","Fee Schedule","","","","","1.03","Fee Schedule","","","","","1.03","Fee Schedule","","","52","","1.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","","52","","1.03","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% of Medicaid interim rate","0.77","75","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.03","150","","","Percent of Total Billed Charges","neg_dollar:$1.60;150% of Medicaid interim rate","0.82","80","","","Percent of Total Billed Charges","neg_dollar:$0.82;Percent of Total Billed Charges","0.95","92","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.03","Fee Schedule","","1.00","1.00",""
"IBUPROFEN 200 MG PO TABS","","","00904-7914-61","NDC","637","RC","","Facility","Outpatient","200","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN","","","00990-7902-09","NDC","250","RC","","Facility","Outpatient","1","EA","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"DEXTROSE 5 % IV SOLN","","","00990-7922-02","NDC","250","RC","","Facility","Outpatient","1","EA","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"DEXTROSE 5 % IV BOLUS","","","00990-7922-03","NDC","250","RC","","Facility","Outpatient","1","EA","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"DEXTROSE 5 % IV SOLN","","","00990-7922-03","NDC","250","RC","","Facility","Outpatient","1","EA","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"DEXTROSE 5 % IV BOLUS","","","00990-7922-09","NDC","250","RC","","Facility","Outpatient","1","EA","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"DEXTROSE 5 % IV SOLN","","","00990-7922-09","NDC","250","RC","","Facility","Outpatient","1","EA","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
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"SODIUM CHLORIDE 0.9 % IV SOLN","","","00990-7983-09","NDC","250","RC","","Facility","Outpatient","1","UN","59.39","59.39","","","","59.39","Fee Schedule","","","","","59.39","Fee Schedule","","","","","59.39","Fee Schedule","","","52","","59.39","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","30.88","52","","","Percent of Total Billed Charges","neg_dollar:$30.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.88","52","","","Percent of Total Billed Charges","neg_dollar:$30.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.07","86","","","Percent of Total Billed Charges","neg_dollar:$51.07","41.57","70","","","Percent of Total Billed Charges","neg_dollar:$41.57","","52","","59.39","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","34.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.89;102% of Medicaid interim rate","44.54","75","","","Percent of Total Billed Charges","neg_dollar:$44.54","51.07","86","","","Percent of Total Billed Charges","neg_dollar:$51.07","41.57","70","","","Percent of Total Billed Charges","neg_dollar:$41.57","33.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.85;103.5% of Medicaid interim rate","59.39","150","","","Percent of Total Billed Charges","neg_dollar:$91.82;150% of Medicaid interim rate","47.51","80","","","Percent of Total Billed Charges","neg_dollar:$47.51;Percent of Total Billed Charges","54.63","92","","","Percent of Total Billed Charges","neg_dollar:$54.63","30.88","52","","","Percent of Total Billed Charges","neg_dollar:$30.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","59.39","Fee Schedule","","30.00","59.00",""
"SODIUM CHLORIDE 0.9 % IV SOLN","","","00990-7983-55","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.9 % IV SOLN","","","00990-7984-13","NDC","250","RC","","Facility","Outpatient","1","UN","55.38","55.38","","","","55.38","Fee Schedule","","","","","55.38","Fee Schedule","","","","","55.38","Fee Schedule","","","52","","55.38","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","28.79","52","","","Percent of Total Billed Charges","neg_dollar:$28.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.79","52","","","Percent of Total Billed Charges","neg_dollar:$28.79;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.63","86","","","Percent of Total Billed Charges","neg_dollar:$47.63","38.76","70","","","Percent of Total Billed Charges","neg_dollar:$38.76","","52","","55.38","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","32.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$32.53;102% of Medicaid interim rate","41.53","75","","","Percent of Total Billed Charges","neg_dollar:$41.53","47.63","86","","","Percent of Total Billed Charges","neg_dollar:$47.63","38.76","70","","","Percent of Total Billed Charges","neg_dollar:$38.76","31.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.56;103.5% of Medicaid interim rate","55.38","150","","","Percent of Total Billed Charges","neg_dollar:$85.62;150% of Medicaid interim rate","44.30","80","","","Percent of Total Billed Charges","neg_dollar:$44.30;Percent of Total Billed Charges","50.95","92","","","Percent of Total Billed Charges","neg_dollar:$50.95","28.79","52","","","Percent of Total Billed Charges","neg_dollar:$28.79;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","55.38","Fee Schedule","","28.00","55.00",""
"SODIUM CHLORIDE 0.9% IV SOLN VIAL-MATE","","","00990-7984-23","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.9 % IV SOLN","","","00990-7984-23","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.9% IV SOLN MINI-BAG PLUS","","","00990-7984-23","NDC","250","RC","","Facility","Outpatient","1","UN","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"SODIUM CHLORIDE 0.45 % IV SOLN","","","00990-7985-09","NDC","250","RC","","Facility","Outpatient","1","EA","60","60.00","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","","","60.00","Fee Schedule","","","52","","60.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","","52","","60.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","35.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$35.24;102% of Medicaid interim rate","45.00","75","","","Percent of Total Billed Charges","neg_dollar:$45","51.60","86","","","Percent of Total Billed Charges","neg_dollar:$51.60","42.00","70","","","Percent of Total Billed Charges","neg_dollar:$42","34.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.19;103.5% of Medicaid interim rate","60.00","150","","","Percent of Total Billed Charges","neg_dollar:$92.76;150% of Medicaid interim rate","48.00","80","","","Percent of Total Billed Charges","neg_dollar:$48;Percent of Total Billed Charges","55.20","92","","","Percent of Total Billed Charges","neg_dollar:$55.20","31.20","52","","","Percent of Total Billed Charges","neg_dollar:$31.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","60.00","Fee Schedule","","31.00","60.00",""
"MAGNESIUM OXIDE 400 MG WRAPPER","","","10006-70028","NDC","250","RC","","Facility","Outpatient","1","EA","1.07","1.07","","","","1.07","Fee Schedule","","","","","1.07","Fee Schedule","","","","","1.07","Fee Schedule","","","52","","1.07","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.74","70","","","Percent of Total Billed Charges","neg_dollar:$0.74","","52","","1.07","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% of Medicaid interim rate","0.80","75","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.74","70","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;103.5% of Medicaid interim rate","1.07","150","","","Percent of Total Billed Charges","neg_dollar:$1.65;150% of Medicaid interim rate","0.85","80","","","Percent of Total Billed Charges","neg_dollar:$0.85;Percent of Total Billed Charges","0.98","92","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.55","52","","","Percent of Total Billed Charges","neg_dollar:$0.55;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.07","Fee Schedule","","1.00","1.00",""
"MAGNESIUM OXIDE 400 MG WRAPPER","","","10006-70028","NDC","637","RC","","Facility","Outpatient","1","EA","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"EYE WASH OP SOLN","","","10119-00252","NDC","250","RC","","Facility","Outpatient","1","EA","5.55","5.55","","","","5.55","Fee Schedule","","","","","5.55","Fee Schedule","","","","","5.55","Fee Schedule","","","52","","5.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.77","86","","","Percent of Total Billed Charges","neg_dollar:$4.77","3.88","70","","","Percent of Total Billed Charges","neg_dollar:$3.88","","52","","5.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.26;102% of Medicaid interim rate","4.16","75","","","Percent of Total Billed Charges","neg_dollar:$4.16","4.77","86","","","Percent of Total Billed Charges","neg_dollar:$4.77","3.88","70","","","Percent of Total Billed Charges","neg_dollar:$3.88","3.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.16;103.5% of Medicaid interim rate","5.55","150","","","Percent of Total Billed Charges","neg_dollar:$8.58;150% of Medicaid interim rate","4.44","80","","","Percent of Total Billed Charges","neg_dollar:$4.44;Percent of Total Billed Charges","5.10","92","","","Percent of Total Billed Charges","neg_dollar:$5.10","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.55","Fee Schedule","","2.00","5.00",""
"OXYCODONE HCL 5 MG PO TABS","","","10702-018-01","NDC","250","RC","","Facility","Outpatient","5","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"SILVER NITRATE-POT NITRATE 75-25 % EX MISC","","","12870-0001-1","NDC","250","RC","","Facility","Outpatient","1","EA","4.65","4.65","","","","4.65","Fee Schedule","","","","","4.65","Fee Schedule","","","","","4.65","Fee Schedule","","","52","","4.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.42","52","","","Percent of Total Billed Charges","neg_dollar:$2.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.42","52","","","Percent of Total Billed Charges","neg_dollar:$2.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","86","","","Percent of Total Billed Charges","neg_dollar:$4","3.25","70","","","Percent of Total Billed Charges","neg_dollar:$3.25","","52","","4.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.73;102% of Medicaid interim rate","3.49","75","","","Percent of Total Billed Charges","neg_dollar:$3.49","4.00","86","","","Percent of Total Billed Charges","neg_dollar:$4","3.25","70","","","Percent of Total Billed Charges","neg_dollar:$3.25","2.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.65;103.5% of Medicaid interim rate","4.65","150","","","Percent of Total Billed Charges","neg_dollar:$7.19;150% of Medicaid interim rate","3.72","80","","","Percent of Total Billed Charges","neg_dollar:$3.72;Percent of Total Billed Charges","4.28","92","","","Percent of Total Billed Charges","neg_dollar:$4.28","2.42","52","","","Percent of Total Billed Charges","neg_dollar:$2.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.65","Fee Schedule","","2.00","4.00",""
"AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR","","","16714-294-01","NDC","250","RC","","Facility","Outpatient","1","EA","28.50","28.50","","","","28.50","Fee Schedule","","","","","28.50","Fee Schedule","","","","","28.50","Fee Schedule","","","52","","28.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.82","52","","","Percent of Total Billed Charges","neg_dollar:$14.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.82","52","","","Percent of Total Billed Charges","neg_dollar:$14.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.50","86","","","Percent of Total Billed Charges","neg_dollar:$24.50","19.95","70","","","Percent of Total Billed Charges","neg_dollar:$19.95","","52","","28.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","16.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.74;102% of Medicaid interim rate","21.37","75","","","Percent of Total Billed Charges","neg_dollar:$21.37","24.50","86","","","Percent of Total Billed Charges","neg_dollar:$24.50","19.95","70","","","Percent of Total Billed Charges","neg_dollar:$19.95","16.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$16.24;103.5% of Medicaid interim rate","28.50","150","","","Percent of Total Billed Charges","neg_dollar:$44.06;150% of Medicaid interim rate","22.80","80","","","Percent of Total Billed Charges","neg_dollar:$22.80;Percent of Total Billed Charges","26.22","92","","","Percent of Total Billed Charges","neg_dollar:$26.22","14.82","52","","","Percent of Total Billed Charges","neg_dollar:$14.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","28.50","Fee Schedule","","14.00","28.00",""
"FLUORESCEIN SODIUM 1 MG OP STRP","","","17238-900-30","NDC","250","RC","","Facility","Outpatient","1","EA","10.70","10.70","","","","10.70","Fee Schedule","","","","","10.70","Fee Schedule","","","","","10.70","Fee Schedule","","","52","","10.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.56","52","","","Percent of Total Billed Charges","neg_dollar:$5.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.56","52","","","Percent of Total Billed Charges","neg_dollar:$5.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.20","86","","","Percent of Total Billed Charges","neg_dollar:$9.20","7.48","70","","","Percent of Total Billed Charges","neg_dollar:$7.48","","52","","10.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.28;102% of Medicaid interim rate","8.02","75","","","Percent of Total Billed Charges","neg_dollar:$8.02","9.20","86","","","Percent of Total Billed Charges","neg_dollar:$9.20","7.48","70","","","Percent of Total Billed Charges","neg_dollar:$7.48","6.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.09;103.5% of Medicaid interim rate","10.70","150","","","Percent of Total Billed Charges","neg_dollar:$16.54;150% of Medicaid interim rate","8.56","80","","","Percent of Total Billed Charges","neg_dollar:$8.56;Percent of Total Billed Charges","9.84","92","","","Percent of Total Billed Charges","neg_dollar:$9.84","5.56","52","","","Percent of Total Billed Charges","neg_dollar:$5.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.70","Fee Schedule","","5.00","10.00",""
"FLUORESCEIN SODIUM 1 MG OP STRP","","","17238-900-99","NDC","250","RC","","Facility","Outpatient","1","EA","10.75","10.75","","","","10.75","Fee Schedule","","","","","10.75","Fee Schedule","","","","","10.75","Fee Schedule","","","52","","10.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.24","86","","","Percent of Total Billed Charges","neg_dollar:$9.24","7.52","70","","","Percent of Total Billed Charges","neg_dollar:$7.52","","52","","10.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.31;102% of Medicaid interim rate","8.06","75","","","Percent of Total Billed Charges","neg_dollar:$8.06","9.24","86","","","Percent of Total Billed Charges","neg_dollar:$9.24","7.52","70","","","Percent of Total Billed Charges","neg_dollar:$7.52","6.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.12;103.5% of Medicaid interim rate","10.75","150","","","Percent of Total Billed Charges","neg_dollar:$16.62;150% of Medicaid interim rate","8.60","80","","","Percent of Total Billed Charges","neg_dollar:$8.60;Percent of Total Billed Charges","9.89","92","","","Percent of Total Billed Charges","neg_dollar:$9.89","5.59","52","","","Percent of Total Billed Charges","neg_dollar:$5.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.75","Fee Schedule","","5.00","10.00",""
"CALCIUM CARB-CHOLECALCIFEROL 600-10 MG-MCG PO TABS","","","20555-01700","NDC","250","RC","","Facility","Outpatient","1","UN","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"MELATONIN 3 MG PO TABS","","","20555-03601","NDC","250","RC","","Facility","Outpatient","3","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"I-VITE PROTECT PO TABS","","","24208-432-62","NDC","250","RC","","Facility","Outpatient","1","EA","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","","52","","1.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.15","Fee Schedule","","1.00","1.00",""
"GENTAMICIN SULFATE 0.3 % OP SOLN","","","24208-580-60","NDC","250","RC","","Facility","Outpatient","1","UN","49.80","49.80","","","","49.80","Fee Schedule","","","","","49.80","Fee Schedule","","","","","49.80","Fee Schedule","","","52","","49.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","25.89","52","","","Percent of Total Billed Charges","neg_dollar:$25.89;102% Medicare Outpatient Cost to Charge Ratio of 52%","25.89","52","","","Percent of Total Billed Charges","neg_dollar:$25.89;102% Medicare Outpatient Cost to Charge Ratio of 52%","42.82","86","","","Percent of Total Billed Charges","neg_dollar:$42.82","34.85","70","","","Percent of Total Billed Charges","neg_dollar:$34.85","","52","","49.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","29.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.25;102% of Medicaid interim rate","37.34","75","","","Percent of Total Billed Charges","neg_dollar:$37.34","42.82","86","","","Percent of Total Billed Charges","neg_dollar:$42.82","34.85","70","","","Percent of Total Billed Charges","neg_dollar:$34.85","28.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.38;103.5% of Medicaid interim rate","49.80","150","","","Percent of Total Billed Charges","neg_dollar:$76.99;150% of Medicaid interim rate","39.84","80","","","Percent of Total Billed Charges","neg_dollar:$39.84;Percent of Total Billed Charges","45.81","92","","","Percent of Total Billed Charges","neg_dollar:$45.81","25.89","52","","","Percent of Total Billed Charges","neg_dollar:$25.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","49.80","Fee Schedule","","25.00","49.00",""
"HEALTHY EYES SUPERVISION 2 PO CAPS","","","24208-69760","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"PROPARACAINE HCL 0.5 % OP SOLN","","","24208-730-06","NDC","250","RC","","Facility","Outpatient","1","EA","49.10","49.10","","","","49.10","Fee Schedule","","","","","49.10","Fee Schedule","","","","","49.10","Fee Schedule","","","52","","49.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","25.53","52","","","Percent of Total Billed Charges","neg_dollar:$25.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","25.53","52","","","Percent of Total Billed Charges","neg_dollar:$25.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","42.22","86","","","Percent of Total Billed Charges","neg_dollar:$42.22","34.37","70","","","Percent of Total Billed Charges","neg_dollar:$34.37","","52","","49.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","28.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.84;102% of Medicaid interim rate","36.82","75","","","Percent of Total Billed Charges","neg_dollar:$36.82","42.22","86","","","Percent of Total Billed Charges","neg_dollar:$42.22","34.37","70","","","Percent of Total Billed Charges","neg_dollar:$34.37","27.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.98;103.5% of Medicaid interim rate","49.10","150","","","Percent of Total Billed Charges","neg_dollar:$75.91;150% of Medicaid interim rate","39.28","80","","","Percent of Total Billed Charges","neg_dollar:$39.28;Percent of Total Billed Charges","45.17","92","","","Percent of Total Billed Charges","neg_dollar:$45.17","25.53","52","","","Percent of Total Billed Charges","neg_dollar:$25.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","49.10","Fee Schedule","","25.00","49.00",""
"ERYTHROMYCIN 5 MG/GM OP OINT","","","24208-910-55","NDC","250","RC","","Facility","Outpatient","1","GM","27.25","27.25","","","","27.25","Fee Schedule","","","","","27.25","Fee Schedule","","","","","27.25","Fee Schedule","","","52","","27.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.43","86","","","Percent of Total Billed Charges","neg_dollar:$23.43","19.07","70","","","Percent of Total Billed Charges","neg_dollar:$19.07","","52","","27.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$16;102% of Medicaid interim rate","20.43","75","","","Percent of Total Billed Charges","neg_dollar:$20.43","23.43","86","","","Percent of Total Billed Charges","neg_dollar:$23.43","19.07","70","","","Percent of Total Billed Charges","neg_dollar:$19.07","15.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.53;103.5% of Medicaid interim rate","27.25","150","","","Percent of Total Billed Charges","neg_dollar:$42.12;150% of Medicaid interim rate","21.80","80","","","Percent of Total Billed Charges","neg_dollar:$21.80;Percent of Total Billed Charges","25.07","92","","","Percent of Total Billed Charges","neg_dollar:$25.07","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","27.25","Fee Schedule","","14.00","27.00",""
"ERYTHROMYCIN 5 MG/GM OP OINT","","","24208-910-55","NDC","637","RC","","Facility","Outpatient","1","GM","27.25","27.25","","","","27.25","Fee Schedule","","","","","27.25","Fee Schedule","101% of Medicare Fee Schedule","","","","27.25","Fee Schedule","","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","27.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","27.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","23.43","86","","","Percent of Total Billed Charges","neg_dollar:$23.43","19.07","70","","","Percent of Total Billed Charges","neg_dollar:$19.07","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;105% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$16;102% of Medicaid interim rate","20.43","75","","","Percent of Total Billed Charges","neg_dollar:$20.43","23.43","86","","","Percent of Total Billed Charges","neg_dollar:$23.43","19.07","70","","","Percent of Total Billed Charges","neg_dollar:$19.07","15.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.53;103.5% of Medicaid interim rate","27.25","150","","","Percent of Total Billed Charges","neg_dollar:$42.12;150% of Medicaid interim rate","21.80","80","","","Percent of Total Billed Charges","neg_dollar:$21.80;Percent of Total Billed Charges","25.07","92","","","Percent of Total Billed Charges","neg_dollar:$25.07","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.17","52","","","Percent of Total Billed Charges","neg_dollar:$14.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","14.00","27.00",""
"LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY","","","25021-673-77","NDC","250","RC","","Facility","Outpatient","1","EA","8.56","8.56","","","","8.56","Fee Schedule","","","","","8.56","Fee Schedule","","","","","8.56","Fee Schedule","","","52","","8.56","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.45","52","","","Percent of Total Billed Charges","neg_dollar:$4.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.45","52","","","Percent of Total Billed Charges","neg_dollar:$4.45;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.36","86","","","Percent of Total Billed Charges","neg_dollar:$7.36","5.99","70","","","Percent of Total Billed Charges","neg_dollar:$5.99","","52","","8.56","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.03;102% of Medicaid interim rate","6.42","75","","","Percent of Total Billed Charges","neg_dollar:$6.42","7.36","86","","","Percent of Total Billed Charges","neg_dollar:$7.36","5.99","70","","","Percent of Total Billed Charges","neg_dollar:$5.99","4.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.88;103.5% of Medicaid interim rate","8.56","150","","","Percent of Total Billed Charges","neg_dollar:$13.24;150% of Medicaid interim rate","6.85","80","","","Percent of Total Billed Charges","neg_dollar:$6.85;Percent of Total Billed Charges","7.88","92","","","Percent of Total Billed Charges","neg_dollar:$7.88","4.45","52","","","Percent of Total Billed Charges","neg_dollar:$4.45;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","8.56","Fee Schedule","","4.00","8.00",""
"IRBESARTAN 150 MG PO TABS","","","31722-730-90","NDC","250","RC","","Facility","Outpatient","1","EA","0.95","0.95","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","","52","","0.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.71","75","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;103.5% of Medicaid interim rate","0.95","150","","","Percent of Total Billed Charges","neg_dollar:$1.46;150% of Medicaid interim rate","0.76","80","","","Percent of Total Billed Charges","neg_dollar:$0.76;Percent of Total Billed Charges","0.87","92","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.95","Fee Schedule","","1.00","1.00",""
"PIOGLITAZONE HCL 30 MG PO TABS","","","33342-055-07","NDC","250","RC","","Facility","Outpatient","30","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"KETOROLAC TROMETHAMINE 10 MG PO TABS","","","35573-450-02","NDC","250","RC","","Facility","Outpatient","10","ME","2","2.00","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","","52","","2.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.00","Fee Schedule","","1.00","2.00",""
"METOPROLOL TARTRATE 5 MG/5ML IV SOLN","","","36000-033-10","NDC","250","RC","","Facility","Outpatient","1","EA","90.02","90.02","","","","90.02","Fee Schedule","","","","","90.02","Fee Schedule","","","","","90.02","Fee Schedule","","","52","","90.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.81","52","","","Percent of Total Billed Charges","neg_dollar:$46.81;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.81","52","","","Percent of Total Billed Charges","neg_dollar:$46.81;102% Medicare Outpatient Cost to Charge Ratio of 52%","77.42","86","","","Percent of Total Billed Charges","neg_dollar:$77.42","63.02","70","","","Percent of Total Billed Charges","neg_dollar:$63.02","","52","","90.02","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.89;102% of Medicaid interim rate","67.52","75","","","Percent of Total Billed Charges","neg_dollar:$67.52","77.42","86","","","Percent of Total Billed Charges","neg_dollar:$77.42","63.02","70","","","Percent of Total Billed Charges","neg_dollar:$63.02","51.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.31;103.5% of Medicaid interim rate","90.02","150","","","Percent of Total Billed Charges","neg_dollar:$139.19;150% of Medicaid interim rate","72.02","80","","","Percent of Total Billed Charges","neg_dollar:$72.02;Percent of Total Billed Charges","82.82","92","","","Percent of Total Billed Charges","neg_dollar:$82.82","46.81","52","","","Percent of Total Billed Charges","neg_dollar:$46.81;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","90.02","Fee Schedule","","46.00","90.00",""
"TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN","","","42023-104-01","NDC","250","RC","","Facility","Outpatient","1","EA","106.70","106.70","","","","106.70","Fee Schedule","","","","","106.70","Fee Schedule","","","","","106.70","Fee Schedule","","","52","","106.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","55.48","52","","","Percent of Total Billed Charges","neg_dollar:$55.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","55.48","52","","","Percent of Total Billed Charges","neg_dollar:$55.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","91.76","86","","","Percent of Total Billed Charges","neg_dollar:$91.76","74.69","70","","","Percent of Total Billed Charges","neg_dollar:$74.69","","52","","106.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","62.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$62.68;102% of Medicaid interim rate","80.02","75","","","Percent of Total Billed Charges","neg_dollar:$80.02","91.76","86","","","Percent of Total Billed Charges","neg_dollar:$91.76","74.69","70","","","Percent of Total Billed Charges","neg_dollar:$74.69","60.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$60.81;103.5% of Medicaid interim rate","106.70","150","","","Percent of Total Billed Charges","neg_dollar:$164.96;150% of Medicaid interim rate","85.36","80","","","Percent of Total Billed Charges","neg_dollar:$85.36;Percent of Total Billed Charges","98.16","92","","","Percent of Total Billed Charges","neg_dollar:$98.16","55.48","52","","","Percent of Total Billed Charges","neg_dollar:$55.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","106.70","Fee Schedule","","55.00","106.00",""
"EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN","","","42023-216-25","NDC","250","RC","","Facility","Outpatient","1","EA","144.43","144.43","","","","144.43","Fee Schedule","","","","","144.43","Fee Schedule","","","","","144.43","Fee Schedule","","","52","","144.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","75.10","52","","","Percent of Total Billed Charges","neg_dollar:$75.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","75.10","52","","","Percent of Total Billed Charges","neg_dollar:$75.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","124.21","86","","","Percent of Total Billed Charges","neg_dollar:$124.21","101.10","70","","","Percent of Total Billed Charges","neg_dollar:$101.10","","52","","144.43","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","84.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$84.85;102% of Medicaid interim rate","108.32","75","","","Percent of Total Billed Charges","neg_dollar:$108.32","124.21","86","","","Percent of Total Billed Charges","neg_dollar:$124.21","101.10","70","","","Percent of Total Billed Charges","neg_dollar:$101.10","82.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$82.32;103.5% of Medicaid interim rate","144.43","150","","","Percent of Total Billed Charges","neg_dollar:$223.30;150% of Medicaid interim rate","115.55","80","","","Percent of Total Billed Charges","neg_dollar:$115.55;Percent of Total Billed Charges","132.88","92","","","Percent of Total Billed Charges","neg_dollar:$132.88","75.10","52","","","Percent of Total Billed Charges","neg_dollar:$75.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","144.43","Fee Schedule","","75.00","144.00",""
"EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN","","","42023-216-25","NDC","250","RC","","Facility","Outpatient","1","EA","18.03","18.03","","","","18.03","Fee Schedule","","","","","18.03","Fee Schedule","","","","","18.03","Fee Schedule","","","52","","18.03","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.37","52","","","Percent of Total Billed Charges","neg_dollar:$9.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.37","52","","","Percent of Total Billed Charges","neg_dollar:$9.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.50","86","","","Percent of Total Billed Charges","neg_dollar:$15.50","12.62","70","","","Percent of Total Billed Charges","neg_dollar:$12.62","","52","","18.03","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.59;102% of Medicaid interim rate","13.52","75","","","Percent of Total Billed Charges","neg_dollar:$13.52","15.50","86","","","Percent of Total Billed Charges","neg_dollar:$15.50","12.62","70","","","Percent of Total Billed Charges","neg_dollar:$12.62","10.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.27;103.5% of Medicaid interim rate","18.03","150","","","Percent of Total Billed Charges","neg_dollar:$27.87;150% of Medicaid interim rate","14.42","80","","","Percent of Total Billed Charges","neg_dollar:$14.42;Percent of Total Billed Charges","16.58","92","","","Percent of Total Billed Charges","neg_dollar:$16.58","9.37","52","","","Percent of Total Billed Charges","neg_dollar:$9.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","18.03","Fee Schedule","","9.00","18.00",""
"VANCOMYCIN HCL 125 MG PO CAPS","","","42494-450-20","NDC","250","RC","","Facility","Outpatient","125","ME","3.25","3.25","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","","","52","","3.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","","52","","3.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.90;102% of Medicaid interim rate","2.43","75","","","Percent of Total Billed Charges","neg_dollar:$2.43","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.85;103.5% of Medicaid interim rate","3.25","150","","","Percent of Total Billed Charges","neg_dollar:$5.02;150% of Medicaid interim rate","2.60","80","","","Percent of Total Billed Charges","neg_dollar:$2.60;Percent of Total Billed Charges","2.99","92","","","Percent of Total Billed Charges","neg_dollar:$2.99","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.25","Fee Schedule","","1.00","3.00",""
"NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN","","","43066-997-01","NDC","250","RC","","Facility","Outpatient","1","ML","96.83","96.83","","","","96.83","Fee Schedule","","","","","96.83","Fee Schedule","","","","","96.83","Fee Schedule","","","52","","96.83","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","50.35","52","","","Percent of Total Billed Charges","neg_dollar:$50.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.35","52","","","Percent of Total Billed Charges","neg_dollar:$50.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.27","86","","","Percent of Total Billed Charges","neg_dollar:$83.27","67.78","70","","","Percent of Total Billed Charges","neg_dollar:$67.78","","52","","96.83","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","56.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.89;102% of Medicaid interim rate","72.62","75","","","Percent of Total Billed Charges","neg_dollar:$72.62","83.27","86","","","Percent of Total Billed Charges","neg_dollar:$83.27","67.78","70","","","Percent of Total Billed Charges","neg_dollar:$67.78","55.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.19;103.5% of Medicaid interim rate","96.83","150","","","Percent of Total Billed Charges","neg_dollar:$149.71;150% of Medicaid interim rate","77.46","80","","","Percent of Total Billed Charges","neg_dollar:$77.46;Percent of Total Billed Charges","89.08","92","","","Percent of Total Billed Charges","neg_dollar:$89.08","50.35","52","","","Percent of Total Billed Charges","neg_dollar:$50.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","96.83","Fee Schedule","","50.00","96.00",""
"NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN","","","43066-997-10","NDC","250","RC","","Facility","Outpatient","1","ML","97.50","97.50","","","","97.50","Fee Schedule","","","","","97.50","Fee Schedule","","","","","97.50","Fee Schedule","","","52","","97.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","50.70","52","","","Percent of Total Billed Charges","neg_dollar:$50.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.70","52","","","Percent of Total Billed Charges","neg_dollar:$50.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.85","86","","","Percent of Total Billed Charges","neg_dollar:$83.85","68.25","70","","","Percent of Total Billed Charges","neg_dollar:$68.25","","52","","97.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","57.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.28;102% of Medicaid interim rate","73.12","75","","","Percent of Total Billed Charges","neg_dollar:$73.12","83.85","86","","","Percent of Total Billed Charges","neg_dollar:$83.85","68.25","70","","","Percent of Total Billed Charges","neg_dollar:$68.25","55.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.57;103.5% of Medicaid interim rate","97.50","150","","","Percent of Total Billed Charges","neg_dollar:$150.73;150% of Medicaid interim rate","78.00","80","","","Percent of Total Billed Charges","neg_dollar:$78;Percent of Total Billed Charges","89.70","92","","","Percent of Total Billed Charges","neg_dollar:$89.70","50.70","52","","","Percent of Total Billed Charges","neg_dollar:$50.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","97.50","Fee Schedule","","50.00","97.00",""
"ORPHENADRINE CITRATE ER 100 MG PO TB12","","","43386-480-24","NDC","250","RC","","Facility","Outpatient","100","ME","1.85","1.85","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","","52","","1.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;103.5% of Medicaid interim rate","1.85","150","","","Percent of Total Billed Charges","neg_dollar:$2.86;150% of Medicaid interim rate","1.48","80","","","Percent of Total Billed Charges","neg_dollar:$1.48;Percent of Total Billed Charges","1.70","92","","","Percent of Total Billed Charges","neg_dollar:$1.70","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.85","Fee Schedule","","1.00","1.00",""
"ENALAPRIL MALEATE 5 MG PO TABS","","","43547-546-10","NDC","250","RC","","Facility","Outpatient","5","ME","0.51","0.51","","","","0.51","Fee Schedule","","","","","0.51","Fee Schedule","","","","","0.51","Fee Schedule","","","52","","0.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","86","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","","52","","0.51","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.30;102% of Medicaid interim rate","0.38","75","","","Percent of Total Billed Charges","neg_dollar:$0.38","0.44","86","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;103.5% of Medicaid interim rate","0.51","150","","","Percent of Total Billed Charges","neg_dollar:$0.79;150% of Medicaid interim rate","0.41","80","","","Percent of Total Billed Charges","neg_dollar:$0.41;Percent of Total Billed Charges","0.47","92","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.51","Fee Schedule","","1.00","1.00",""
"SILVER SULFADIAZINE 1 % EX CREA","","","43598-210-25","NDC","250","RC","","Facility","Outpatient","1","EA","18.75","18.75","","","","18.75","Fee Schedule","","","","","18.75","Fee Schedule","","","","","18.75","Fee Schedule","","","52","","18.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.75","52","","","Percent of Total Billed Charges","neg_dollar:$9.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.75","52","","","Percent of Total Billed Charges","neg_dollar:$9.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.12","86","","","Percent of Total Billed Charges","neg_dollar:$16.12","13.12","70","","","Percent of Total Billed Charges","neg_dollar:$13.12","","52","","18.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","11.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.01;102% of Medicaid interim rate","14.06","75","","","Percent of Total Billed Charges","neg_dollar:$14.06","16.12","86","","","Percent of Total Billed Charges","neg_dollar:$16.12","13.12","70","","","Percent of Total Billed Charges","neg_dollar:$13.12","10.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.68;103.5% of Medicaid interim rate","18.75","150","","","Percent of Total Billed Charges","neg_dollar:$28.98;150% of Medicaid interim rate","15.00","80","","","Percent of Total Billed Charges","neg_dollar:$15;Percent of Total Billed Charges","17.25","92","","","Percent of Total Billed Charges","neg_dollar:$17.25","9.75","52","","","Percent of Total Billed Charges","neg_dollar:$9.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","18.75","Fee Schedule","","9.00","18.00",""
"DICLOFENAC SODIUM 1 % EX GEL","","","43598-977-10","NDC","250","RC","","Facility","Outpatient","1","EA","23.70","23.70","","","","23.70","Fee Schedule","","","","","23.70","Fee Schedule","","","","","23.70","Fee Schedule","","","52","","23.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.38","86","","","Percent of Total Billed Charges","neg_dollar:$20.38","16.59","70","","","Percent of Total Billed Charges","neg_dollar:$16.59","","52","","23.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.92;102% of Medicaid interim rate","17.77","75","","","Percent of Total Billed Charges","neg_dollar:$17.77","20.38","86","","","Percent of Total Billed Charges","neg_dollar:$20.38","16.59","70","","","Percent of Total Billed Charges","neg_dollar:$16.59","13.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.50;103.5% of Medicaid interim rate","23.70","150","","","Percent of Total Billed Charges","neg_dollar:$36.64;150% of Medicaid interim rate","18.96","80","","","Percent of Total Billed Charges","neg_dollar:$18.96;Percent of Total Billed Charges","21.80","92","","","Percent of Total Billed Charges","neg_dollar:$21.80","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","23.70","Fee Schedule","","12.00","23.00",""
"DICLOFENAC SODIUM 1 % EX GEL","","","43598-977-10","NDC","637","RC","","Facility","Outpatient","1","EA","23.70","23.70","","","","23.70","Fee Schedule","","","","","23.70","Fee Schedule","101% of Medicare Fee Schedule","","","","23.70","Fee Schedule","","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","23.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.38","86","","","Percent of Total Billed Charges","neg_dollar:$20.38","16.59","70","","","Percent of Total Billed Charges","neg_dollar:$16.59","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","13.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.92;102% of Medicaid interim rate","17.77","75","","","Percent of Total Billed Charges","neg_dollar:$17.77","20.38","86","","","Percent of Total Billed Charges","neg_dollar:$20.38","16.59","70","","","Percent of Total Billed Charges","neg_dollar:$16.59","13.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.50;103.5% of Medicaid interim rate","23.70","150","","","Percent of Total Billed Charges","neg_dollar:$36.64;150% of Medicaid interim rate","18.96","80","","","Percent of Total Billed Charges","neg_dollar:$18.96;Percent of Total Billed Charges","21.80","92","","","Percent of Total Billed Charges","neg_dollar:$21.80","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.32","52","","","Percent of Total Billed Charges","neg_dollar:$12.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","12.00","23.00",""
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA","","","45802-064-35","NDC","250","RC","","Facility","Outpatient","1","UN","14.10","14.10","","","","14.10","Fee Schedule","","","","","14.10","Fee Schedule","","","","","14.10","Fee Schedule","","","52","","14.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.33","52","","","Percent of Total Billed Charges","neg_dollar:$7.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.33","52","","","Percent of Total Billed Charges","neg_dollar:$7.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.12","86","","","Percent of Total Billed Charges","neg_dollar:$12.12","9.87","70","","","Percent of Total Billed Charges","neg_dollar:$9.87","","52","","14.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","8.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.28;102% of Medicaid interim rate","10.57","75","","","Percent of Total Billed Charges","neg_dollar:$10.57","12.12","86","","","Percent of Total Billed Charges","neg_dollar:$12.12","9.87","70","","","Percent of Total Billed Charges","neg_dollar:$9.87","8.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$8.03;103.5% of Medicaid interim rate","14.10","150","","","Percent of Total Billed Charges","neg_dollar:$21.79;150% of Medicaid interim rate","11.28","80","","","Percent of Total Billed Charges","neg_dollar:$11.28;Percent of Total Billed Charges","12.97","92","","","Percent of Total Billed Charges","neg_dollar:$12.97","7.33","52","","","Percent of Total Billed Charges","neg_dollar:$7.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","14.10","Fee Schedule","","7.00","14.00",""
"ACETAMINOPHEN 650 MG RE SUPP","","","45802-730-30","NDC","250","RC","","Facility","Outpatient","1","ME","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","","52","","1.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.45","Fee Schedule","","1.00","1.00",""
"DICLOFENAC SODIUM 1 % EX GEL","","","45802-953-01","NDC","250","RC","","Facility","Outpatient","1","UN","24.05","24.05","","","","24.05","Fee Schedule","","","","","24.05","Fee Schedule","","","","","24.05","Fee Schedule","","","52","","24.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.50","52","","","Percent of Total Billed Charges","neg_dollar:$12.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.50","52","","","Percent of Total Billed Charges","neg_dollar:$12.50;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.68","86","","","Percent of Total Billed Charges","neg_dollar:$20.68","16.83","70","","","Percent of Total Billed Charges","neg_dollar:$16.83","","52","","24.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","14.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$14.12;102% of Medicaid interim rate","18.03","75","","","Percent of Total Billed Charges","neg_dollar:$18.03","20.68","86","","","Percent of Total Billed Charges","neg_dollar:$20.68","16.83","70","","","Percent of Total Billed Charges","neg_dollar:$16.83","13.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.70;103.5% of Medicaid interim rate","24.05","150","","","Percent of Total Billed Charges","neg_dollar:$37.18;150% of Medicaid interim rate","19.24","80","","","Percent of Total Billed Charges","neg_dollar:$19.24;Percent of Total Billed Charges","22.12","92","","","Percent of Total Billed Charges","neg_dollar:$22.12","12.50","52","","","Percent of Total Billed Charges","neg_dollar:$12.50;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","24.05","Fee Schedule","","12.00","24.00",""
"OXYMETAZOLINE HCL 0.05 % NA SOLN","","","46122-165-10","NDC","250","RC","","Facility","Outpatient","1","UN","13.60","13.60","","","","13.60","Fee Schedule","","","","","13.60","Fee Schedule","","","","","13.60","Fee Schedule","","","52","","13.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","7.07","52","","","Percent of Total Billed Charges","neg_dollar:$7.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.07","52","","","Percent of Total Billed Charges","neg_dollar:$7.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.69","86","","","Percent of Total Billed Charges","neg_dollar:$11.69","9.52","70","","","Percent of Total Billed Charges","neg_dollar:$9.52","","52","","13.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.98;102% of Medicaid interim rate","10.20","75","","","Percent of Total Billed Charges","neg_dollar:$10.20","11.69","86","","","Percent of Total Billed Charges","neg_dollar:$11.69","9.52","70","","","Percent of Total Billed Charges","neg_dollar:$9.52","7.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.75;103.5% of Medicaid interim rate","13.60","150","","","Percent of Total Billed Charges","neg_dollar:$21.02;150% of Medicaid interim rate","10.88","80","","","Percent of Total Billed Charges","neg_dollar:$10.88;Percent of Total Billed Charges","12.51","92","","","Percent of Total Billed Charges","neg_dollar:$12.51","7.07","52","","","Percent of Total Billed Charges","neg_dollar:$7.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","13.60","Fee Schedule","","7.00","13.00",""
"ARTIFICIAL TEARS OINTMENT WRAPPER","","","46122-757-37","NDC","250","RC","","Facility","Outpatient","1","EA","17.90","17.90","","","","17.90","Fee Schedule","","","","","17.90","Fee Schedule","","","","","17.90","Fee Schedule","","","52","","17.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.39","86","","","Percent of Total Billed Charges","neg_dollar:$15.39","12.52","70","","","Percent of Total Billed Charges","neg_dollar:$12.52","","52","","17.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.51;102% of Medicaid interim rate","13.42","75","","","Percent of Total Billed Charges","neg_dollar:$13.42","15.39","86","","","Percent of Total Billed Charges","neg_dollar:$15.39","12.52","70","","","Percent of Total Billed Charges","neg_dollar:$12.52","10.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.20;103.5% of Medicaid interim rate","17.90","150","","","Percent of Total Billed Charges","neg_dollar:$27.67;150% of Medicaid interim rate","14.32","80","","","Percent of Total Billed Charges","neg_dollar:$14.32;Percent of Total Billed Charges","16.46","92","","","Percent of Total Billed Charges","neg_dollar:$16.46","9.30","52","","","Percent of Total Billed Charges","neg_dollar:$9.30;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","17.90","Fee Schedule","","9.00","17.00",""
"FENTANYL 25 MCG/HR TD PT72","","","47781-424-11","NDC","250","RC","","Facility","Outpatient","1","UN","9.60","9.60","","","","9.60","Fee Schedule","","","","","9.60","Fee Schedule","","","","","9.60","Fee Schedule","","","52","","9.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.99","52","","","Percent of Total Billed Charges","neg_dollar:$4.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.99","52","","","Percent of Total Billed Charges","neg_dollar:$4.99;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.25","86","","","Percent of Total Billed Charges","neg_dollar:$8.25","6.72","70","","","Percent of Total Billed Charges","neg_dollar:$6.72","","52","","9.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.63;102% of Medicaid interim rate","7.19","75","","","Percent of Total Billed Charges","neg_dollar:$7.19","8.25","86","","","Percent of Total Billed Charges","neg_dollar:$8.25","6.72","70","","","Percent of Total Billed Charges","neg_dollar:$6.72","5.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.47;103.5% of Medicaid interim rate","9.60","150","","","Percent of Total Billed Charges","neg_dollar:$14.84;150% of Medicaid interim rate","7.68","80","","","Percent of Total Billed Charges","neg_dollar:$7.68;Percent of Total Billed Charges","8.83","92","","","Percent of Total Billed Charges","neg_dollar:$8.83","4.99","52","","","Percent of Total Billed Charges","neg_dollar:$4.99;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","9.60","Fee Schedule","","4.00","9.00",""
"FENTANYL 50 MCG/HR TD PT72","","","47781-426-11","NDC","250","RC","","Facility","Outpatient","1","EA","16.20","16.20","","","","16.20","Fee Schedule","","","","","16.20","Fee Schedule","","","","","16.20","Fee Schedule","","","52","","16.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.42","52","","","Percent of Total Billed Charges","neg_dollar:$8.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.42","52","","","Percent of Total Billed Charges","neg_dollar:$8.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.93","86","","","Percent of Total Billed Charges","neg_dollar:$13.93","11.33","70","","","Percent of Total Billed Charges","neg_dollar:$11.33","","52","","16.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.51;102% of Medicaid interim rate","12.14","75","","","Percent of Total Billed Charges","neg_dollar:$12.14","13.93","86","","","Percent of Total Billed Charges","neg_dollar:$13.93","11.33","70","","","Percent of Total Billed Charges","neg_dollar:$11.33","9.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.23;103.5% of Medicaid interim rate","16.20","150","","","Percent of Total Billed Charges","neg_dollar:$25.04;150% of Medicaid interim rate","12.96","80","","","Percent of Total Billed Charges","neg_dollar:$12.96;Percent of Total Billed Charges","14.90","92","","","Percent of Total Billed Charges","neg_dollar:$14.90","8.42","52","","","Percent of Total Billed Charges","neg_dollar:$8.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","16.20","Fee Schedule","","8.00","16.00",""
"CULTURELLE PO CAPS","","","49100-38164","NDC","250","RC","","Facility","Outpatient","1","EA","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","","52","","1.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.70","Fee Schedule","","1.00","1.00",""
"TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN","","","49281-752-21","NDC","250","RC","","Facility","Outpatient","1","EA","107.75","107.75","","","","107.75","Fee Schedule","","","","","107.75","Fee Schedule","","","","","107.75","Fee Schedule","","","52","","107.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","56.03","52","","","Percent of Total Billed Charges","neg_dollar:$56.03;102% Medicare Outpatient Cost to Charge Ratio of 52%","56.03","52","","","Percent of Total Billed Charges","neg_dollar:$56.03;102% Medicare Outpatient Cost to Charge Ratio of 52%","92.66","86","","","Percent of Total Billed Charges","neg_dollar:$92.66","75.42","70","","","Percent of Total Billed Charges","neg_dollar:$75.42","","52","","107.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","63.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$63.30;102% of Medicaid interim rate","80.81","75","","","Percent of Total Billed Charges","neg_dollar:$80.81","92.66","86","","","Percent of Total Billed Charges","neg_dollar:$92.66","75.42","70","","","Percent of Total Billed Charges","neg_dollar:$75.42","61.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$61.41;103.5% of Medicaid interim rate","107.75","150","","","Percent of Total Billed Charges","neg_dollar:$166.58;150% of Medicaid interim rate","86.20","80","","","Percent of Total Billed Charges","neg_dollar:$86.20;Percent of Total Billed Charges","99.13","92","","","Percent of Total Billed Charges","neg_dollar:$99.13","56.03","52","","","Percent of Total Billed Charges","neg_dollar:$56.03;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","107.75","Fee Schedule","","56.00","107.00",""
"EZETIMIBE 10 MG PO TABS","","","50228-379-90","NDC","250","RC","","Facility","Outpatient","10","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"BACLOFEN 10 MG PO TABS","","","50268-106-11","NDC","250","RC","","Facility","Outpatient","10","ME","1.65","1.65","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","","","","","1.65","Fee Schedule","","","52","","1.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","","52","","1.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.23","75","","","Percent of Total Billed Charges","neg_dollar:$1.23","1.41","86","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.15","70","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.94;103.5% of Medicaid interim rate","1.65","150","","","Percent of Total Billed Charges","neg_dollar:$2.55;150% of Medicaid interim rate","1.32","80","","","Percent of Total Billed Charges","neg_dollar:$1.32;Percent of Total Billed Charges","1.51","92","","","Percent of Total Billed Charges","neg_dollar:$1.51","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.65","Fee Schedule","","1.00","1.00",""
"BENAZEPRIL HCL 10 MG PO TABS","","","50268-110-15","NDC","250","RC","","Facility","Outpatient","10","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"BUMETANIDE 1 MG PO TABS","","","50268-131-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"BUMETANIDE 1 MG PO TABS","","","50268-131-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","101% of Medicare Fee Schedule","","","","1.40","Fee Schedule","","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CALCIUM CARBONATE 1250 (500 CA) MG PO CHEW","","","50268-149-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.09","1.09","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","","52","","1.09","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.09","150","","","Percent of Total Billed Charges","neg_dollar:$1.68;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.00","92","","","Percent of Total Billed Charges","neg_dollar:$1","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.09","Fee Schedule","","1.00","1.00",""
"CEPHALEXIN 500 MG PO CAPS","","","50268-152-11","NDC","250","RC","","Facility","Outpatient","500","ME","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","","52","","1.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.31;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.50","Fee Schedule","","1.00","1.00",""
"MELOXICAM 7.5 MG PO TABS","","","50268-525-15","NDC","250","RC","","Facility","Outpatient","1","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"NORTRIPTYLINE HCL 25 MG PO CAPS","","","50268-604-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","","","50268-639-11","NDC","250","RC","","Facility","Outpatient","40","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"PANTOPRAZOLE SODIUM 40 MG PO TBEC","","","50268-639-11","NDC","637","RC","","Facility","Outpatient","40","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","","","50268-684-11","NDC","250","RC","","Facility","Outpatient","5","ME","1.95","1.95","","","","1.95","Fee Schedule","","","","","1.95","Fee Schedule","","","","","1.95","Fee Schedule","","","52","","1.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","52","","","Percent of Total Billed Charges","neg_dollar:$1.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","52","","","Percent of Total Billed Charges","neg_dollar:$1.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.67","86","","","Percent of Total Billed Charges","neg_dollar:$1.67","1.36","70","","","Percent of Total Billed Charges","neg_dollar:$1.36","","52","","1.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;102% of Medicaid interim rate","1.46","75","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.67","86","","","Percent of Total Billed Charges","neg_dollar:$1.67","1.36","70","","","Percent of Total Billed Charges","neg_dollar:$1.36","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;103.5% of Medicaid interim rate","1.95","150","","","Percent of Total Billed Charges","neg_dollar:$3.01;150% of Medicaid interim rate","1.56","80","","","Percent of Total Billed Charges","neg_dollar:$1.56;Percent of Total Billed Charges","1.79","92","","","Percent of Total Billed Charges","neg_dollar:$1.79","1.01","52","","","Percent of Total Billed Charges","neg_dollar:$1.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.95","Fee Schedule","","1.00","1.00",""
"PROCHLORPERAZINE MALEATE 5 MG PO TABS","","","50268-684-11","NDC","637","RC","","Facility","Outpatient","5","ME","1.85","1.85","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","101% of Medicare Fee Schedule","","","","1.85","Fee Schedule","","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;103.5% of Medicaid interim rate","1.85","150","","","Percent of Total Billed Charges","neg_dollar:$2.86;150% of Medicaid interim rate","1.48","80","","","Percent of Total Billed Charges","neg_dollar:$1.48;Percent of Total Billed Charges","1.70","92","","","Percent of Total Billed Charges","neg_dollar:$1.70","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TORSEMIDE 20 MG PO TABS","","","50268-756-11","NDC","250","RC","","Facility","Outpatient","20","ME","0.79","0.79","","","","0.79","Fee Schedule","","","","","0.79","Fee Schedule","","","","","0.79","Fee Schedule","","","52","","0.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","","52","","0.79","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.59","75","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.79","150","","","Percent of Total Billed Charges","neg_dollar:$1.23;150% of Medicaid interim rate","0.63","80","","","Percent of Total Billed Charges","neg_dollar:$0.63;Percent of Total Billed Charges","0.73","92","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.79","Fee Schedule","","1.00","1.00",""
"TIZANIDINE HCL 4 MG PO TABS","","","50268-760-11","NDC","250","RC","","Facility","Outpatient","4","ME","1.72","1.72","","","","1.72","Fee Schedule","","","","","1.72","Fee Schedule","","","","","1.72","Fee Schedule","","","52","","1.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.48","86","","","Percent of Total Billed Charges","neg_dollar:$1.48","1.20","70","","","Percent of Total Billed Charges","neg_dollar:$1.20","","52","","1.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.01;102% of Medicaid interim rate","1.29","75","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.48","86","","","Percent of Total Billed Charges","neg_dollar:$1.48","1.20","70","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.98;103.5% of Medicaid interim rate","1.72","150","","","Percent of Total Billed Charges","neg_dollar:$2.66;150% of Medicaid interim rate","1.38","80","","","Percent of Total Billed Charges","neg_dollar:$1.38;Percent of Total Billed Charges","1.58","92","","","Percent of Total Billed Charges","neg_dollar:$1.58","0.89","52","","","Percent of Total Billed Charges","neg_dollar:$0.89;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.72","Fee Schedule","","1.00","1.00",""
"TIZANIDINE HCL 4 MG PO TABS","","","50268-760-11","NDC","637","RC","","Facility","Outpatient","4","ME","1.80","1.80","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","101% of Medicare Fee Schedule","","","","1.80","Fee Schedule","","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;102% of Medicaid interim rate","1.35","75","","","Percent of Total Billed Charges","neg_dollar:$1.35","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;103.5% of Medicaid interim rate","1.80","150","","","Percent of Total Billed Charges","neg_dollar:$2.78;150% of Medicaid interim rate","1.44","80","","","Percent of Total Billed Charges","neg_dollar:$1.44;Percent of Total Billed Charges","1.65","92","","","Percent of Total Billed Charges","neg_dollar:$1.65","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"VALACYCLOVIR HCL 500 MG PO TABS","","","50268-788-11","NDC","250","RC","","Facility","Outpatient","500","ME","2.60","2.60","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","52","","2.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","","52","","2.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.52;102% of Medicaid interim rate","1.95","75","","","Percent of Total Billed Charges","neg_dollar:$1.95","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","1.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.48;103.5% of Medicaid interim rate","2.60","150","","","Percent of Total Billed Charges","neg_dollar:$4.01;150% of Medicaid interim rate","2.08","80","","","Percent of Total Billed Charges","neg_dollar:$2.08;Percent of Total Billed Charges","2.39","92","","","Percent of Total Billed Charges","neg_dollar:$2.39","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.60","Fee Schedule","","1.00","2.00",""
"RIVAROXABAN 10 MG PO TABS","","","50458-580-30","NDC","250","RC","","Facility","Outpatient","10","ME","23.51","23.51","","","","23.51","Fee Schedule","","","","","23.51","Fee Schedule","","","","","23.51","Fee Schedule","","","52","","23.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","12.22","52","","","Percent of Total Billed Charges","neg_dollar:$12.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","12.22","52","","","Percent of Total Billed Charges","neg_dollar:$12.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.22","86","","","Percent of Total Billed Charges","neg_dollar:$20.22","16.45","70","","","Percent of Total Billed Charges","neg_dollar:$16.45","","52","","23.51","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.81;102% of Medicaid interim rate","17.63","75","","","Percent of Total Billed Charges","neg_dollar:$17.63","20.22","86","","","Percent of Total Billed Charges","neg_dollar:$20.22","16.45","70","","","Percent of Total Billed Charges","neg_dollar:$16.45","13.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.40;103.5% of Medicaid interim rate","23.51","150","","","Percent of Total Billed Charges","neg_dollar:$36.35;150% of Medicaid interim rate","18.81","80","","","Percent of Total Billed Charges","neg_dollar:$18.81;Percent of Total Billed Charges","21.63","92","","","Percent of Total Billed Charges","neg_dollar:$21.63","12.22","52","","","Percent of Total Billed Charges","neg_dollar:$12.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","23.51","Fee Schedule","","12.00","23.00",""
"METOPROLOL TARTRATE 25 MG PO TABS","","","51079-255-01","NDC","250","RC","","Facility","Outpatient","25","ME","1.09","1.09","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","","","","","1.09","Fee Schedule","","","52","","1.09","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","","52","","1.09","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.09","150","","","Percent of Total Billed Charges","neg_dollar:$1.69;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.00","92","","","Percent of Total Billed Charges","neg_dollar:$1","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.09","Fee Schedule","","1.00","1.00",""
"METOPROLOL TARTRATE 25 MG PO TABS","","","51079-255-01","NDC","637","RC","","Facility","Outpatient","25","ME","0.85","0.85","","","","0.85","Fee Schedule","","","","","0.85","Fee Schedule","101% of Medicare Fee Schedule","","","","0.85","Fee Schedule","","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% of Medicaid interim rate","0.63","75","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.73","86","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","70","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;103.5% of Medicaid interim rate","0.85","150","","","Percent of Total Billed Charges","neg_dollar:$1.31;150% of Medicaid interim rate","0.68","80","","","Percent of Total Billed Charges","neg_dollar:$0.68;Percent of Total Billed Charges","0.78","92","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","52","","","Percent of Total Billed Charges","neg_dollar:$0.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METOPROLOL TARTRATE 25 MG PO TABS","","","51079-255-01","NDC","637","RC","","Facility","Outpatient","25","ME","0.80","0.80","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","101% of Medicare Fee Schedule","","","","0.80","Fee Schedule","","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.60","75","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.80","150","","","Percent of Total Billed Charges","neg_dollar:$1.23;150% of Medicaid interim rate","0.64","80","","","Percent of Total Billed Charges","neg_dollar:$0.64;Percent of Total Billed Charges","0.73","92","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"METOPROLOL TARTRATE 25 MG PO TABS","","","51079-255-20","NDC","637","RC","","Facility","Outpatient","25","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","101% of Medicare Fee Schedule","","","","1.15","Fee Schedule","","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DIAZEPAM 5 MG PO TABS","","","51079-285-01","NDC","250","RC","","Facility","Outpatient","5","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"LEVOTHYROXINE SODIUM 50 MCG PO TABS","","","51079-440-01","NDC","250","RC","","Facility","Outpatient","50","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"LEVOTHYROXINE SODIUM 75 MCG PO TABS","","","51079-441-01","NDC","250","RC","","Facility","Outpatient","75","EA","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"ATENOLOL 50 MG PO TABS","","","51079-684-01","NDC","250","RC","","Facility","Outpatient","50","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","","52","","1.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.15","Fee Schedule","","1.00","1.00",""
"SUCRALFATE 1 G PO TABS","","","51079-753-01","NDC","250","RC","","Facility","Outpatient","1","GM","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"LEVETIRACETAM 500 MG PO TABS","","","51079-821-01","NDC","250","RC","","Facility","Outpatient","500","ME","1.04","1.04","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","52","","1.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","","52","","1.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.04","150","","","Percent of Total Billed Charges","neg_dollar:$1.61;150% of Medicaid interim rate","0.83","80","","","Percent of Total Billed Charges","neg_dollar:$0.83;Percent of Total Billed Charges","0.95","92","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.04","Fee Schedule","","1.00","1.00",""
"LEVETIRACETAM 500 MG PO TABS","","","51079-821-01","NDC","637","RC","","Facility","Outpatient","500","ME","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","101% of Medicare Fee Schedule","","","","1.70","Fee Schedule","","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"BUSPIRONE HCL 5 MG PO TABS","","","51079-985-01","NDC","250","RC","","Facility","Outpatient","5","ME","0.62","0.62","","","","0.62","Fee Schedule","","","","","0.62","Fee Schedule","","","","","0.62","Fee Schedule","","","52","","0.62","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","86","","","Percent of Total Billed Charges","neg_dollar:$0.53","0.43","70","","","Percent of Total Billed Charges","neg_dollar:$0.43","","52","","0.62","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.36;102% of Medicaid interim rate","0.46","75","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.53","86","","","Percent of Total Billed Charges","neg_dollar:$0.53","0.43","70","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.35;103.5% of Medicaid interim rate","0.62","150","","","Percent of Total Billed Charges","neg_dollar:$0.96;150% of Medicaid interim rate","0.50","80","","","Percent of Total Billed Charges","neg_dollar:$0.50;Percent of Total Billed Charges","0.57","92","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.32","52","","","Percent of Total Billed Charges","neg_dollar:$0.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.62","Fee Schedule","","1.00","1.00",""
"SODIUM BICARBONATE 4.2 % IV SOLN","","","51754-5012-1","NDC","250","RC","","Facility","Outpatient","1","UN","89","89.00","","","","89.00","Fee Schedule","","","","","89.00","Fee Schedule","","","","","89.00","Fee Schedule","","","52","","89.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.28","52","","","Percent of Total Billed Charges","neg_dollar:$46.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.28","52","","","Percent of Total Billed Charges","neg_dollar:$46.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.53","86","","","Percent of Total Billed Charges","neg_dollar:$76.53","62.30","70","","","Percent of Total Billed Charges","neg_dollar:$62.30","","52","","89.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.28;102% of Medicaid interim rate","66.75","75","","","Percent of Total Billed Charges","neg_dollar:$66.75","76.53","86","","","Percent of Total Billed Charges","neg_dollar:$76.53","62.30","70","","","Percent of Total Billed Charges","neg_dollar:$62.30","50.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.73;103.5% of Medicaid interim rate","89.00","150","","","Percent of Total Billed Charges","neg_dollar:$137.59;150% of Medicaid interim rate","71.20","80","","","Percent of Total Billed Charges","neg_dollar:$71.20;Percent of Total Billed Charges","81.88","92","","","Percent of Total Billed Charges","neg_dollar:$81.88","46.28","52","","","Percent of Total Billed Charges","neg_dollar:$46.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","89.00","Fee Schedule","","46.00","89.00",""
"LIDOCAINE HCL (PF) 1 % IJ SOLN","","","55150-162-05","NDC","250","RC","","Facility","Outpatient","1","UN","77.96","77.96","","","","77.96","Fee Schedule","","","","","77.96","Fee Schedule","","","","","77.96","Fee Schedule","","","52","","77.96","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","40.54","52","","","Percent of Total Billed Charges","neg_dollar:$40.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","40.54","52","","","Percent of Total Billed Charges","neg_dollar:$40.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","67.04","86","","","Percent of Total Billed Charges","neg_dollar:$67.04","54.57","70","","","Percent of Total Billed Charges","neg_dollar:$54.57","","52","","77.96","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","45.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$45.80;102% of Medicaid interim rate","58.47","75","","","Percent of Total Billed Charges","neg_dollar:$58.47","67.04","86","","","Percent of Total Billed Charges","neg_dollar:$67.04","54.57","70","","","Percent of Total Billed Charges","neg_dollar:$54.57","44.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$44.43;103.5% of Medicaid interim rate","77.96","150","","","Percent of Total Billed Charges","neg_dollar:$120.53;150% of Medicaid interim rate","62.36","80","","","Percent of Total Billed Charges","neg_dollar:$62.36;Percent of Total Billed Charges","71.72","92","","","Percent of Total Billed Charges","neg_dollar:$71.72","40.54","52","","","Percent of Total Billed Charges","neg_dollar:$40.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","77.96","Fee Schedule","","40.00","77.00",""
"LIDOCAINE HCL (PF) 2 % IJ SOLN","","","55150-165-05","NDC","250","RC","","Facility","Outpatient","1","EA","91.36","91.36","","","","91.36","Fee Schedule","","","","","91.36","Fee Schedule","","","","","91.36","Fee Schedule","","","52","","91.36","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.51","52","","","Percent of Total Billed Charges","neg_dollar:$47.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.51","52","","","Percent of Total Billed Charges","neg_dollar:$47.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.57","86","","","Percent of Total Billed Charges","neg_dollar:$78.57","63.95","70","","","Percent of Total Billed Charges","neg_dollar:$63.95","","52","","91.36","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.67;102% of Medicaid interim rate","68.52","75","","","Percent of Total Billed Charges","neg_dollar:$68.52","78.57","86","","","Percent of Total Billed Charges","neg_dollar:$78.57","63.95","70","","","Percent of Total Billed Charges","neg_dollar:$63.95","52.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.08;103.5% of Medicaid interim rate","91.36","150","","","Percent of Total Billed Charges","neg_dollar:$141.26;150% of Medicaid interim rate","73.09","80","","","Percent of Total Billed Charges","neg_dollar:$73.09;Percent of Total Billed Charges","84.05","92","","","Percent of Total Billed Charges","neg_dollar:$84.05","47.51","52","","","Percent of Total Billed Charges","neg_dollar:$47.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","91.36","Fee Schedule","","47.00","91.00",""
"TRANEXAMIC ACID 1000 MG/10ML IV SOLN","","","55150-188-10","NDC","250","RC","","Facility","Outpatient","1","UN","95.53","95.53","","","","95.53","Fee Schedule","","","","","95.53","Fee Schedule","","","","","95.53","Fee Schedule","","","52","","95.53","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","49.67","52","","","Percent of Total Billed Charges","neg_dollar:$49.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","49.67","52","","","Percent of Total Billed Charges","neg_dollar:$49.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","82.15","86","","","Percent of Total Billed Charges","neg_dollar:$82.15","66.87","70","","","Percent of Total Billed Charges","neg_dollar:$66.87","","52","","95.53","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","56.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.12;102% of Medicaid interim rate","71.64","75","","","Percent of Total Billed Charges","neg_dollar:$71.64","82.15","86","","","Percent of Total Billed Charges","neg_dollar:$82.15","66.87","70","","","Percent of Total Billed Charges","neg_dollar:$66.87","54.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.45;103.5% of Medicaid interim rate","95.53","150","","","Percent of Total Billed Charges","neg_dollar:$147.69;150% of Medicaid interim rate","76.42","80","","","Percent of Total Billed Charges","neg_dollar:$76.42;Percent of Total Billed Charges","87.89","92","","","Percent of Total Billed Charges","neg_dollar:$87.89","49.67","52","","","Percent of Total Billed Charges","neg_dollar:$49.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","95.53","Fee Schedule","","49.00","95.00",""
"DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN","","","55150-209-02","NDC","250","RC","","Facility","Outpatient","1","EA","6.15","6.15","","","","6.15","Fee Schedule","","","","","6.15","Fee Schedule","","","","","6.15","Fee Schedule","","","52","","6.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.19","52","","","Percent of Total Billed Charges","neg_dollar:$3.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.19","52","","","Percent of Total Billed Charges","neg_dollar:$3.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.28","86","","","Percent of Total Billed Charges","neg_dollar:$5.28","4.30","70","","","Percent of Total Billed Charges","neg_dollar:$4.30","","52","","6.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.61;102% of Medicaid interim rate","4.61","75","","","Percent of Total Billed Charges","neg_dollar:$4.61","5.28","86","","","Percent of Total Billed Charges","neg_dollar:$5.28","4.30","70","","","Percent of Total Billed Charges","neg_dollar:$4.30","3.50","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.50;103.5% of Medicaid interim rate","6.15","150","","","Percent of Total Billed Charges","neg_dollar:$9.50;150% of Medicaid interim rate","4.92","80","","","Percent of Total Billed Charges","neg_dollar:$4.92;Percent of Total Billed Charges","5.65","92","","","Percent of Total Billed Charges","neg_dollar:$5.65","3.19","52","","","Percent of Total Billed Charges","neg_dollar:$3.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","6.15","Fee Schedule","","3.00","6.00",""
"DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN","","","55150-209-02","NDC","250","RC","","Facility","Outpatient","1","EA","101.90","101.90","","","","101.90","Fee Schedule","","","","","101.90","Fee Schedule","","","","","101.90","Fee Schedule","","","52","","101.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","52.98","52","","","Percent of Total Billed Charges","neg_dollar:$52.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.98","52","","","Percent of Total Billed Charges","neg_dollar:$52.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","87.63","86","","","Percent of Total Billed Charges","neg_dollar:$87.63","71.33","70","","","Percent of Total Billed Charges","neg_dollar:$71.33","","52","","101.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","59.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.86;102% of Medicaid interim rate","76.42","75","","","Percent of Total Billed Charges","neg_dollar:$76.42","87.63","86","","","Percent of Total Billed Charges","neg_dollar:$87.63","71.33","70","","","Percent of Total Billed Charges","neg_dollar:$71.33","58.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$58.08;103.5% of Medicaid interim rate","101.90","150","","","Percent of Total Billed Charges","neg_dollar:$157.54;150% of Medicaid interim rate","81.52","80","","","Percent of Total Billed Charges","neg_dollar:$81.52;Percent of Total Billed Charges","93.74","92","","","Percent of Total Billed Charges","neg_dollar:$93.74","52.98","52","","","Percent of Total Billed Charges","neg_dollar:$52.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","101.90","Fee Schedule","","52.00","101.00",""
"ROCURONIUM BROMIDE 100 MG/10ML IV SOLN","","","55150-226-10","NDC","250","RC","","Facility","Outpatient","1","UN","110.11","110.11","","","","110.11","Fee Schedule","","","","","110.11","Fee Schedule","","","","","110.11","Fee Schedule","","","52","","110.11","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","57.26","52","","","Percent of Total Billed Charges","neg_dollar:$57.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","57.26","52","","","Percent of Total Billed Charges","neg_dollar:$57.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","94.70","86","","","Percent of Total Billed Charges","neg_dollar:$94.70","77.08","70","","","Percent of Total Billed Charges","neg_dollar:$77.08","","52","","110.11","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","64.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.69;102% of Medicaid interim rate","82.58","75","","","Percent of Total Billed Charges","neg_dollar:$82.58","94.70","86","","","Percent of Total Billed Charges","neg_dollar:$94.70","77.08","70","","","Percent of Total Billed Charges","neg_dollar:$77.08","62.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$62.76;103.5% of Medicaid interim rate","110.11","150","","","Percent of Total Billed Charges","neg_dollar:$170.24;150% of Medicaid interim rate","88.09","80","","","Percent of Total Billed Charges","neg_dollar:$88.09;Percent of Total Billed Charges","101.30","92","","","Percent of Total Billed Charges","neg_dollar:$101.30","57.26","52","","","Percent of Total Billed Charges","neg_dollar:$57.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","110.11","Fee Schedule","","57.00","110.00",""
"ROCURONIUM BROMIDE 100 MG/10ML IV SOLN","","","55150-226-10","NDC","250","RC","","Facility","Outpatient","1","UN","4.18","4.18","","","","4.18","Fee Schedule","","","","","4.18","Fee Schedule","","","","","4.18","Fee Schedule","","","52","","4.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.17","52","","","Percent of Total Billed Charges","neg_dollar:$2.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.17","52","","","Percent of Total Billed Charges","neg_dollar:$2.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.59","86","","","Percent of Total Billed Charges","neg_dollar:$3.59","2.92","70","","","Percent of Total Billed Charges","neg_dollar:$2.92","","52","","4.18","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.45;102% of Medicaid interim rate","3.13","75","","","Percent of Total Billed Charges","neg_dollar:$3.13","3.59","86","","","Percent of Total Billed Charges","neg_dollar:$3.59","2.92","70","","","Percent of Total Billed Charges","neg_dollar:$2.92","2.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.38;103.5% of Medicaid interim rate","4.18","150","","","Percent of Total Billed Charges","neg_dollar:$6.46;150% of Medicaid interim rate","3.34","80","","","Percent of Total Billed Charges","neg_dollar:$3.34;Percent of Total Billed Charges","3.84","92","","","Percent of Total Billed Charges","neg_dollar:$3.84","2.17","52","","","Percent of Total Billed Charges","neg_dollar:$2.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.18","Fee Schedule","","2.00","4.00",""
"KETAMINE HCL 10 MG/ML IJ SOLN","","","55150-438-01","NDC","250","RC","","Facility","Outpatient","1","UN","101.25","101.25","","","","101.25","Fee Schedule","","","","","101.25","Fee Schedule","","","","","101.25","Fee Schedule","","","52","","101.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","52.65","52","","","Percent of Total Billed Charges","neg_dollar:$52.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.65","52","","","Percent of Total Billed Charges","neg_dollar:$52.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","87.08","86","","","Percent of Total Billed Charges","neg_dollar:$87.08","70.87","70","","","Percent of Total Billed Charges","neg_dollar:$70.87","","52","","101.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","59.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.48;102% of Medicaid interim rate","75.94","75","","","Percent of Total Billed Charges","neg_dollar:$75.94","87.08","86","","","Percent of Total Billed Charges","neg_dollar:$87.08","70.87","70","","","Percent of Total Billed Charges","neg_dollar:$70.87","57.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.71;103.5% of Medicaid interim rate","101.25","150","","","Percent of Total Billed Charges","neg_dollar:$156.54;150% of Medicaid interim rate","81.00","80","","","Percent of Total Billed Charges","neg_dollar:$81;Percent of Total Billed Charges","93.15","92","","","Percent of Total Billed Charges","neg_dollar:$93.15","52.65","52","","","Percent of Total Billed Charges","neg_dollar:$52.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","101.25","Fee Schedule","","52.00","101.00",""
"KETAMINE HCL 10 MG/ML IJ SOLN","","","55150-438-10","NDC","250","RC","","Facility","Outpatient","1","ML","126.10","126.10","","","","126.10","Fee Schedule","","","","","126.10","Fee Schedule","","","","","126.10","Fee Schedule","","","52","","126.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","65.57","52","","","Percent of Total Billed Charges","neg_dollar:$65.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","65.57","52","","","Percent of Total Billed Charges","neg_dollar:$65.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","108.44","86","","","Percent of Total Billed Charges","neg_dollar:$108.44","88.27","70","","","Percent of Total Billed Charges","neg_dollar:$88.27","","52","","126.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","74.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$74.08;102% of Medicaid interim rate","94.57","75","","","Percent of Total Billed Charges","neg_dollar:$94.57","108.44","86","","","Percent of Total Billed Charges","neg_dollar:$108.44","88.27","70","","","Percent of Total Billed Charges","neg_dollar:$88.27","71.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.87;103.5% of Medicaid interim rate","126.10","150","","","Percent of Total Billed Charges","neg_dollar:$194.95;150% of Medicaid interim rate","100.88","80","","","Percent of Total Billed Charges","neg_dollar:$100.88;Percent of Total Billed Charges","116.01","92","","","Percent of Total Billed Charges","neg_dollar:$116.01","65.57","52","","","Percent of Total Billed Charges","neg_dollar:$65.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","126.10","Fee Schedule","","65.00","126.00",""
"KETAMINE HCL 10 MG/ML IJ SOLN","","","55150-438-10","NDC","250","RC","","Facility","Outpatient","1","ML","13.32","13.32","","","","13.32","Fee Schedule","","","","","13.32","Fee Schedule","","","","","13.32","Fee Schedule","","","52","","13.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.92","52","","","Percent of Total Billed Charges","neg_dollar:$6.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.92","52","","","Percent of Total Billed Charges","neg_dollar:$6.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.45","86","","","Percent of Total Billed Charges","neg_dollar:$11.45","9.32","70","","","Percent of Total Billed Charges","neg_dollar:$9.32","","52","","13.32","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.82;102% of Medicaid interim rate","9.99","75","","","Percent of Total Billed Charges","neg_dollar:$9.99","11.45","86","","","Percent of Total Billed Charges","neg_dollar:$11.45","9.32","70","","","Percent of Total Billed Charges","neg_dollar:$9.32","7.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.59;103.5% of Medicaid interim rate","13.32","150","","","Percent of Total Billed Charges","neg_dollar:$20.59;150% of Medicaid interim rate","10.65","80","","","Percent of Total Billed Charges","neg_dollar:$10.65;Percent of Total Billed Charges","12.25","92","","","Percent of Total Billed Charges","neg_dollar:$12.25","6.92","52","","","Percent of Total Billed Charges","neg_dollar:$6.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","13.32","Fee Schedule","","6.00","13.00",""
"ONDANSETRON 4 MG PO TBDP","","","57237-077-10","NDC","637","RC","","Facility","Outpatient","4","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","101% of Medicare Fee Schedule","","","","1.35","Fee Schedule","","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ONDANSETRON 4 MG PO TBDP","","","57237-077-10","NDC","250","RC","","Facility","Outpatient","4","ME","2.29","2.29","","","","2.29","Fee Schedule","","","","","2.29","Fee Schedule","","","","","2.29","Fee Schedule","","","52","","2.29","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.19","52","","","Percent of Total Billed Charges","neg_dollar:$1.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.19","52","","","Percent of Total Billed Charges","neg_dollar:$1.19;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.97","86","","","Percent of Total Billed Charges","neg_dollar:$1.97","1.60","70","","","Percent of Total Billed Charges","neg_dollar:$1.60","","52","","2.29","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.34;102% of Medicaid interim rate","1.71","75","","","Percent of Total Billed Charges","neg_dollar:$1.71","1.97","86","","","Percent of Total Billed Charges","neg_dollar:$1.97","1.60","70","","","Percent of Total Billed Charges","neg_dollar:$1.60","1.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.30;103.5% of Medicaid interim rate","2.29","150","","","Percent of Total Billed Charges","neg_dollar:$3.54;150% of Medicaid interim rate","1.83","80","","","Percent of Total Billed Charges","neg_dollar:$1.83;Percent of Total Billed Charges","2.10","92","","","Percent of Total Billed Charges","neg_dollar:$2.10","1.19","52","","","Percent of Total Billed Charges","neg_dollar:$1.19;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.29","Fee Schedule","","1.00","2.00",""
"ONDANSETRON 4 MG PO TBDP","","","57237-077-10","NDC","637","RC","","Facility","Outpatient","4","ME","2.91","2.91","","","","2.91","Fee Schedule","","","","","2.91","Fee Schedule","101% of Medicare Fee Schedule","","","","2.91","Fee Schedule","","1.51","52","","","Percent of Total Billed Charges","neg_dollar:$1.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.91","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.50","86","","","Percent of Total Billed Charges","neg_dollar:$2.50","2.03","70","","","Percent of Total Billed Charges","neg_dollar:$2.03","1.51","52","","","Percent of Total Billed Charges","neg_dollar:$1.51;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.71;102% of Medicaid interim rate","2.18","75","","","Percent of Total Billed Charges","neg_dollar:$2.18","2.50","86","","","Percent of Total Billed Charges","neg_dollar:$2.50","2.03","70","","","Percent of Total Billed Charges","neg_dollar:$2.03","1.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.66;103.5% of Medicaid interim rate","2.91","150","","","Percent of Total Billed Charges","neg_dollar:$4.50;150% of Medicaid interim rate","2.33","80","","","Percent of Total Billed Charges","neg_dollar:$2.33;Percent of Total Billed Charges","2.67","92","","","Percent of Total Billed Charges","neg_dollar:$2.67","1.51","52","","","Percent of Total Billed Charges","neg_dollar:$1.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.51","52","","","Percent of Total Billed Charges","neg_dollar:$1.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP","","","57237-316-03","NDC","250","RC","","Facility","Outpatient","1","UN","3.16","3.16","","","","3.16","Fee Schedule","","","","","3.16","Fee Schedule","","","","","3.16","Fee Schedule","","","52","","3.16","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.64","52","","","Percent of Total Billed Charges","neg_dollar:$1.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.64","52","","","Percent of Total Billed Charges","neg_dollar:$1.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.72","86","","","Percent of Total Billed Charges","neg_dollar:$2.72","2.21","70","","","Percent of Total Billed Charges","neg_dollar:$2.21","","52","","3.16","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.86;102% of Medicaid interim rate","2.37","75","","","Percent of Total Billed Charges","neg_dollar:$2.37","2.72","86","","","Percent of Total Billed Charges","neg_dollar:$2.72","2.21","70","","","Percent of Total Billed Charges","neg_dollar:$2.21","1.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.80;103.5% of Medicaid interim rate","3.16","150","","","Percent of Total Billed Charges","neg_dollar:$4.89;150% of Medicaid interim rate","2.53","80","","","Percent of Total Billed Charges","neg_dollar:$2.53;Percent of Total Billed Charges","2.91","92","","","Percent of Total Billed Charges","neg_dollar:$2.91","1.64","52","","","Percent of Total Billed Charges","neg_dollar:$1.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.16","Fee Schedule","","1.00","3.00",""
"BACITRACIN OINTMENT WRAPPER","","","57896-145-14","NDC","250","RC","","Facility","Outpatient","1","EA","7.13","7.13","","","","7.13","Fee Schedule","","","","","7.13","Fee Schedule","","","","","7.13","Fee Schedule","","","52","","7.13","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.70","52","","","Percent of Total Billed Charges","neg_dollar:$3.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.70","52","","","Percent of Total Billed Charges","neg_dollar:$3.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.13","86","","","Percent of Total Billed Charges","neg_dollar:$6.13","4.99","70","","","Percent of Total Billed Charges","neg_dollar:$4.99","","52","","7.13","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","4.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.19;102% of Medicaid interim rate","5.34","75","","","Percent of Total Billed Charges","neg_dollar:$5.34","6.13","86","","","Percent of Total Billed Charges","neg_dollar:$6.13","4.99","70","","","Percent of Total Billed Charges","neg_dollar:$4.99","4.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.06;103.5% of Medicaid interim rate","7.13","150","","","Percent of Total Billed Charges","neg_dollar:$11.02;150% of Medicaid interim rate","5.70","80","","","Percent of Total Billed Charges","neg_dollar:$5.70;Percent of Total Billed Charges","6.56","92","","","Percent of Total Billed Charges","neg_dollar:$6.56","3.70","52","","","Percent of Total Billed Charges","neg_dollar:$3.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","7.13","Fee Schedule","","3.00","7.00",""
"BACITRACIN OINTMENT WRAPPER","","","57896-145-14","NDC","250","RC","","Facility","Outpatient","1","EA","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"BACITRACIN OINTMENT WRAPPER","","","57896-145-14","NDC","637","RC","","Facility","Outpatient","1","EA","5.85","5.85","","","","5.85","Fee Schedule","","","","","5.85","Fee Schedule","101% of Medicare Fee Schedule","","","","5.85","Fee Schedule","","3.04","52","","","Percent of Total Billed Charges","neg_dollar:$3.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","5.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.03","86","","","Percent of Total Billed Charges","neg_dollar:$5.03","4.09","70","","","Percent of Total Billed Charges","neg_dollar:$4.09","3.04","52","","","Percent of Total Billed Charges","neg_dollar:$3.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","3.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.43;102% of Medicaid interim rate","4.38","75","","","Percent of Total Billed Charges","neg_dollar:$4.38","5.03","86","","","Percent of Total Billed Charges","neg_dollar:$5.03","4.09","70","","","Percent of Total Billed Charges","neg_dollar:$4.09","3.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.33;103.5% of Medicaid interim rate","5.85","150","","","Percent of Total Billed Charges","neg_dollar:$9.04;150% of Medicaid interim rate","4.68","80","","","Percent of Total Billed Charges","neg_dollar:$4.68;Percent of Total Billed Charges","5.38","92","","","Percent of Total Billed Charges","neg_dollar:$5.38","3.04","52","","","Percent of Total Billed Charges","neg_dollar:$3.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.04","52","","","Percent of Total Billed Charges","neg_dollar:$3.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","5.00",""
"ARTIFICIAL TEARS OP SOLN WRAPPER","","","57896-184-05","NDC","250","RC","","Facility","Outpatient","1","EA","11.95","11.95","","","","11.95","Fee Schedule","","","","","11.95","Fee Schedule","","","","","11.95","Fee Schedule","","","52","","11.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","","52","","11.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.02;102% of Medicaid interim rate","8.96","75","","","Percent of Total Billed Charges","neg_dollar:$8.96","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.81;103.5% of Medicaid interim rate","11.95","150","","","Percent of Total Billed Charges","neg_dollar:$18.47;150% of Medicaid interim rate","9.56","80","","","Percent of Total Billed Charges","neg_dollar:$9.56;Percent of Total Billed Charges","10.99","92","","","Percent of Total Billed Charges","neg_dollar:$10.99","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","11.95","Fee Schedule","","6.00","11.00",""
"ARTIFICIAL TEARS OP SOLN WRAPPER","","","57896-184-05","NDC","637","RC","","Facility","Outpatient","1","EA","11.95","11.95","","","","11.95","Fee Schedule","","","","","11.95","Fee Schedule","101% of Medicare Fee Schedule","","","","11.95","Fee Schedule","","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","11.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.02;102% of Medicaid interim rate","8.96","75","","","Percent of Total Billed Charges","neg_dollar:$8.96","10.27","86","","","Percent of Total Billed Charges","neg_dollar:$10.27","8.36","70","","","Percent of Total Billed Charges","neg_dollar:$8.36","6.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.81;103.5% of Medicaid interim rate","11.95","150","","","Percent of Total Billed Charges","neg_dollar:$18.47;150% of Medicaid interim rate","9.56","80","","","Percent of Total Billed Charges","neg_dollar:$9.56;Percent of Total Billed Charges","10.99","92","","","Percent of Total Billed Charges","neg_dollar:$10.99","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.21","52","","","Percent of Total Billed Charges","neg_dollar:$6.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","11.00",""
"ACETAMINOPHEN 500 MG PO TABS","","","57896-201-01","NDC","250","RC","","Facility","Outpatient","500","ME","0.30","0.30","","","","0.30","Fee Schedule","","","","","0.30","Fee Schedule","","","","","0.30","Fee Schedule","","","52","","0.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.15","52","","","Percent of Total Billed Charges","neg_dollar:$0.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.15","52","","","Percent of Total Billed Charges","neg_dollar:$0.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.25","86","","","Percent of Total Billed Charges","neg_dollar:$0.25","0.21","70","","","Percent of Total Billed Charges","neg_dollar:$0.21","","52","","0.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.17;102% of Medicaid interim rate","0.22","75","","","Percent of Total Billed Charges","neg_dollar:$0.22","0.25","86","","","Percent of Total Billed Charges","neg_dollar:$0.25","0.21","70","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.17;103.5% of Medicaid interim rate","0.30","150","","","Percent of Total Billed Charges","neg_dollar:$0.46;150% of Medicaid interim rate","0.24","80","","","Percent of Total Billed Charges","neg_dollar:$0.24;Percent of Total Billed Charges","0.27","92","","","Percent of Total Billed Charges","neg_dollar:$0.27","0.15","52","","","Percent of Total Billed Charges","neg_dollar:$0.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.30","Fee Schedule","","1.00","1.00",""
"NITROGLYCERIN 0.4 MG SL SUBL","","","59762-3304-3","NDC","250","RC","","Facility","Outpatient","1","ME","10.95","10.95","","","","10.95","Fee Schedule","","","","","10.95","Fee Schedule","","","","","10.95","Fee Schedule","","","52","","10.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.41","86","","","Percent of Total Billed Charges","neg_dollar:$9.41","7.66","70","","","Percent of Total Billed Charges","neg_dollar:$7.66","","52","","10.95","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.43;102% of Medicaid interim rate","8.21","75","","","Percent of Total Billed Charges","neg_dollar:$8.21","9.41","86","","","Percent of Total Billed Charges","neg_dollar:$9.41","7.66","70","","","Percent of Total Billed Charges","neg_dollar:$7.66","6.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.24;103.5% of Medicaid interim rate","10.95","150","","","Percent of Total Billed Charges","neg_dollar:$16.92;150% of Medicaid interim rate","8.76","80","","","Percent of Total Billed Charges","neg_dollar:$8.76;Percent of Total Billed Charges","10.07","92","","","Percent of Total Billed Charges","neg_dollar:$10.07","5.69","52","","","Percent of Total Billed Charges","neg_dollar:$5.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.95","Fee Schedule","","5.00","10.00",""
"ALPRAZOLAM 0.5 MG PO TABS","","","59762-3720-1","NDC","250","RC","","Facility","Outpatient","1","ME","0.79","0.79","","","","0.79","Fee Schedule","","","","","0.79","Fee Schedule","","","","","0.79","Fee Schedule","","","52","","0.79","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","","52","","0.79","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.59","75","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.79","150","","","Percent of Total Billed Charges","neg_dollar:$1.22;150% of Medicaid interim rate","0.63","80","","","Percent of Total Billed Charges","neg_dollar:$0.63;Percent of Total Billed Charges","0.72","92","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.79","Fee Schedule","","1.00","1.00",""
"ALPRAZOLAM 0.5 MG PO TABS","","","59762-3720-1","NDC","637","RC","","Facility","Outpatient","1","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","101% of Medicare Fee Schedule","","","","1.10","Fee Schedule","","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ATROPINE SULFATE 1 % OP SOLN","","","60219-1748-2","NDC","250","RC","","Facility","Outpatient","1","UN","50","50.00","","","","50.00","Fee Schedule","","","","","50.00","Fee Schedule","","","","","50.00","Fee Schedule","","","52","","50.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;102% Medicare Outpatient Cost to Charge Ratio of 52%","43.00","86","","","Percent of Total Billed Charges","neg_dollar:$43","35.00","70","","","Percent of Total Billed Charges","neg_dollar:$35","","52","","50.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","29.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.37;102% of Medicaid interim rate","37.50","75","","","Percent of Total Billed Charges","neg_dollar:$37.50","43.00","86","","","Percent of Total Billed Charges","neg_dollar:$43","35.00","70","","","Percent of Total Billed Charges","neg_dollar:$35","28.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$28.49;103.5% of Medicaid interim rate","50.00","150","","","Percent of Total Billed Charges","neg_dollar:$77.30;150% of Medicaid interim rate","40.00","80","","","Percent of Total Billed Charges","neg_dollar:$40;Percent of Total Billed Charges","46.00","92","","","Percent of Total Billed Charges","neg_dollar:$46","26.00","52","","","Percent of Total Billed Charges","neg_dollar:$26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","50.00","Fee Schedule","","26.00","50.00",""
"OLANZAPINE 5 MG PO TABS","","","60505-3111-0","NDC","250","RC","","Facility","Outpatient","5","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"CLONIDINE HCL 0.1 MG PO TABS","","","60687-113-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"METFORMIN HCL 850 MG PO TABS","","","60687-143-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"METFORMIN HCL 500 MG PO TABS","","","60687-155-11","NDC","250","RC","","Facility","Outpatient","500","ME","1.08","1.08","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","","","52","","1.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","","52","","1.08","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.76","70","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.08","150","","","Percent of Total Billed Charges","neg_dollar:$1.68;150% of Medicaid interim rate","0.87","80","","","Percent of Total Billed Charges","neg_dollar:$0.87;Percent of Total Billed Charges","1.00","92","","","Percent of Total Billed Charges","neg_dollar:$1","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.08","Fee Schedule","","1.00","1.00",""
"MEMANTINE HCL 5 MG PO TABS","","","60687-173-11","NDC","250","RC","","Facility","Outpatient","5","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"PRAVASTATIN SODIUM 20 MG PO TABS","","","60687-178-11","NDC","250","RC","","Facility","Outpatient","20","ME","1.85","1.85","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","","","1.85","Fee Schedule","","","52","","1.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","","52","","1.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;102% of Medicaid interim rate","1.38","75","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.59","86","","","Percent of Total Billed Charges","neg_dollar:$1.59","1.29","70","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;103.5% of Medicaid interim rate","1.85","150","","","Percent of Total Billed Charges","neg_dollar:$2.86;150% of Medicaid interim rate","1.48","80","","","Percent of Total Billed Charges","neg_dollar:$1.48;Percent of Total Billed Charges","1.70","92","","","Percent of Total Billed Charges","neg_dollar:$1.70","0.96","52","","","Percent of Total Billed Charges","neg_dollar:$0.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.85","Fee Schedule","","1.00","1.00",""
"DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24","","","60687-195-11","NDC","250","RC","","Facility","Outpatient","120","ME","2","2.00","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","","52","","2.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.00","Fee Schedule","","1.00","2.00",""
"DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24","","","60687-195-11","NDC","637","RC","","Facility","Outpatient","120","ME","2","2.00","","","","2.00","Fee Schedule","","","","","2.00","Fee Schedule","101% of Medicare Fee Schedule","","","","2.00","Fee Schedule","","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% of Medicaid interim rate","1.50","75","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.72","86","","","Percent of Total Billed Charges","neg_dollar:$1.72","1.40","70","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.00","150","","","Percent of Total Billed Charges","neg_dollar:$3.09;150% of Medicaid interim rate","1.60","80","","","Percent of Total Billed Charges","neg_dollar:$1.60;Percent of Total Billed Charges","1.84","92","","","Percent of Total Billed Charges","neg_dollar:$1.84","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24","","","60687-206-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.47","1.47","","","","1.47","Fee Schedule","","","","","1.47","Fee Schedule","","","","","1.47","Fee Schedule","","","52","","1.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.26","86","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","","52","","1.47","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.86;102% of Medicaid interim rate","1.10","75","","","Percent of Total Billed Charges","neg_dollar:$1.10","1.26","86","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.84;103.5% of Medicaid interim rate","1.47","150","","","Percent of Total Billed Charges","neg_dollar:$2.28;150% of Medicaid interim rate","1.18","80","","","Percent of Total Billed Charges","neg_dollar:$1.18;Percent of Total Billed Charges","1.35","92","","","Percent of Total Billed Charges","neg_dollar:$1.35","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.47","Fee Schedule","","1.00","1.00",""
"PROPRANOLOL HCL ER 80 MG PO CP24","","","60687-226-11","NDC","250","RC","","Facility","Outpatient","80","ME","3.80","3.80","","","","3.80","Fee Schedule","","","","","3.80","Fee Schedule","","","","","3.80","Fee Schedule","","","52","","3.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.97","52","","","Percent of Total Billed Charges","neg_dollar:$1.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.97","52","","","Percent of Total Billed Charges","neg_dollar:$1.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.26","86","","","Percent of Total Billed Charges","neg_dollar:$3.26","2.65","70","","","Percent of Total Billed Charges","neg_dollar:$2.65","","52","","3.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.23;102% of Medicaid interim rate","2.84","75","","","Percent of Total Billed Charges","neg_dollar:$2.84","3.26","86","","","Percent of Total Billed Charges","neg_dollar:$3.26","2.65","70","","","Percent of Total Billed Charges","neg_dollar:$2.65","2.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.16;103.5% of Medicaid interim rate","3.80","150","","","Percent of Total Billed Charges","neg_dollar:$5.87;150% of Medicaid interim rate","3.04","80","","","Percent of Total Billed Charges","neg_dollar:$3.04;Percent of Total Billed Charges","3.49","92","","","Percent of Total Billed Charges","neg_dollar:$3.49","1.97","52","","","Percent of Total Billed Charges","neg_dollar:$1.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.80","Fee Schedule","","1.00","3.00",""
"LOPERAMIDE HCL 2 MG PO CAPS","","","60687-229-01","NDC","250","RC","","Facility","Outpatient","1","ML","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","","52","","2.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.05","Fee Schedule","","1.00","2.00",""
"LOPERAMIDE HCL 2 MG PO CAPS","","","60687-229-11","NDC","250","RC","","Facility","Outpatient","2","ME","1.90","1.90","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","52","","1.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","","52","","1.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% of Medicaid interim rate","1.42","75","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;103.5% of Medicaid interim rate","1.90","150","","","Percent of Total Billed Charges","neg_dollar:$2.93;150% of Medicaid interim rate","1.52","80","","","Percent of Total Billed Charges","neg_dollar:$1.52;Percent of Total Billed Charges","1.74","92","","","Percent of Total Billed Charges","neg_dollar:$1.74","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.90","Fee Schedule","","1.00","1.00",""
"LOPERAMIDE HCL 2 MG PO CAPS","","","60687-229-11","NDC","637","RC","","Facility","Outpatient","1","UN","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","101% of Medicare Fee Schedule","","","","2.05","Fee Schedule","","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"SERTRALINE HCL 50 MG PO TABS","","","60687-242-11","NDC","250","RC","","Facility","Outpatient","50","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","86","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","","52","","1.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.99","86","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.81","70","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.66;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.79;150% of Medicaid interim rate","0.92","80","","","Percent of Total Billed Charges","neg_dollar:$0.92;Percent of Total Billed Charges","1.06","92","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.60","52","","","Percent of Total Billed Charges","neg_dollar:$0.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.15","Fee Schedule","","1.00","1.00",""
"ROSUVASTATIN CALCIUM 10 MG PO TABS","","","60687-245-11","NDC","637","RC","","Facility","Outpatient","10","EA","2.70","2.70","","","","2.70","Fee Schedule","","","","","2.70","Fee Schedule","101% of Medicare Fee Schedule","","","","2.70","Fee Schedule","","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.32","86","","","Percent of Total Billed Charges","neg_dollar:$2.32","1.89","70","","","Percent of Total Billed Charges","neg_dollar:$1.89","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.58;102% of Medicaid interim rate","2.02","75","","","Percent of Total Billed Charges","neg_dollar:$2.02","2.32","86","","","Percent of Total Billed Charges","neg_dollar:$2.32","1.89","70","","","Percent of Total Billed Charges","neg_dollar:$1.89","1.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.53;103.5% of Medicaid interim rate","2.70","150","","","Percent of Total Billed Charges","neg_dollar:$4.17;150% of Medicaid interim rate","2.16","80","","","Percent of Total Billed Charges","neg_dollar:$2.16;Percent of Total Billed Charges","2.48","92","","","Percent of Total Billed Charges","neg_dollar:$2.48","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"CEFUROXIME AXETIL 250 MG PO TABS","","","60687-272-11","NDC","250","RC","","Facility","Outpatient","250","ME","5.05","5.05","","","","5.05","Fee Schedule","","","","","5.05","Fee Schedule","","","","","5.05","Fee Schedule","","","52","","5.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","","52","","5.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.96;102% of Medicaid interim rate","3.78","75","","","Percent of Total Billed Charges","neg_dollar:$3.78","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.87;103.5% of Medicaid interim rate","5.05","150","","","Percent of Total Billed Charges","neg_dollar:$7.80;150% of Medicaid interim rate","4.04","80","","","Percent of Total Billed Charges","neg_dollar:$4.04;Percent of Total Billed Charges","4.64","92","","","Percent of Total Billed Charges","neg_dollar:$4.64","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.05","Fee Schedule","","2.00","5.00",""
"QUETIAPINE FUMARATE 100 MG PO TABS","","","60687-349-11","NDC","250","RC","","Facility","Outpatient","100","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","","52","","1.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.15","Fee Schedule","","1.00","1.00",""
"DICYCLOMINE HCL 10 MG PO CAPS","","","60687-369-01","NDC","250","RC","","Facility","Outpatient","10","ME","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","","52","","1.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.70","Fee Schedule","","1.00","1.00",""
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU","","","60687-395-79","NDC","250","RC","","Facility","Outpatient","1","EA","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS","","","60687-396-11","NDC","250","RC","","Facility","Outpatient","1","EA","2.04","2.04","","","","2.04","Fee Schedule","","","","","2.04","Fee Schedule","","","","","2.04","Fee Schedule","","","52","","2.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.75","86","","","Percent of Total Billed Charges","neg_dollar:$1.75","1.42","70","","","Percent of Total Billed Charges","neg_dollar:$1.42","","52","","2.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.19;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.75","86","","","Percent of Total Billed Charges","neg_dollar:$1.75","1.42","70","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.04","150","","","Percent of Total Billed Charges","neg_dollar:$3.15;150% of Medicaid interim rate","1.63","80","","","Percent of Total Billed Charges","neg_dollar:$1.63;Percent of Total Billed Charges","1.87","92","","","Percent of Total Billed Charges","neg_dollar:$1.87","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.04","Fee Schedule","","1.00","2.00",""
"METOPROLOL SUCCINATE ER 100 MG PO TB24","","","60687-413-11","NDC","250","RC","","Facility","Outpatient","1","EA","2.70","2.70","","","","2.70","Fee Schedule","","","","","2.70","Fee Schedule","","","","","2.70","Fee Schedule","","","52","","2.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.32","86","","","Percent of Total Billed Charges","neg_dollar:$2.32","1.89","70","","","Percent of Total Billed Charges","neg_dollar:$1.89","","52","","2.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.58;102% of Medicaid interim rate","2.02","75","","","Percent of Total Billed Charges","neg_dollar:$2.02","2.32","86","","","Percent of Total Billed Charges","neg_dollar:$2.32","1.89","70","","","Percent of Total Billed Charges","neg_dollar:$1.89","1.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.53;103.5% of Medicaid interim rate","2.70","150","","","Percent of Total Billed Charges","neg_dollar:$4.17;150% of Medicaid interim rate","2.16","80","","","Percent of Total Billed Charges","neg_dollar:$2.16;Percent of Total Billed Charges","2.48","92","","","Percent of Total Billed Charges","neg_dollar:$2.48","1.40","52","","","Percent of Total Billed Charges","neg_dollar:$1.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.70","Fee Schedule","","1.00","2.00",""
"FINASTERIDE 5 MG PO TABS","","","60687-428-11","NDC","250","RC","","Facility","Outpatient","5","ME","2.10","2.10","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","","52","","2.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% of Medicaid interim rate","1.57","75","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.19;103.5% of Medicaid interim rate","2.10","150","","","Percent of Total Billed Charges","neg_dollar:$3.24;150% of Medicaid interim rate","1.68","80","","","Percent of Total Billed Charges","neg_dollar:$1.68;Percent of Total Billed Charges","1.93","92","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.10","Fee Schedule","","1.00","2.00",""
"FINASTERIDE 5 MG PO TABS","","","60687-428-11","NDC","637","RC","","Facility","Outpatient","5","ME","2.10","2.10","","","","2.10","Fee Schedule","","","","","2.10","Fee Schedule","101% of Medicare Fee Schedule","","","","2.10","Fee Schedule","","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","2.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.23;102% of Medicaid interim rate","1.57","75","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.80","86","","","Percent of Total Billed Charges","neg_dollar:$1.80","1.47","70","","","Percent of Total Billed Charges","neg_dollar:$1.47","1.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.19;103.5% of Medicaid interim rate","2.10","150","","","Percent of Total Billed Charges","neg_dollar:$3.24;150% of Medicaid interim rate","1.68","80","","","Percent of Total Billed Charges","neg_dollar:$1.68;Percent of Total Billed Charges","1.93","92","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","52","","","Percent of Total Billed Charges","neg_dollar:$1.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","2.00",""
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP","","","60687-429-45","NDC","250","RC","","Facility","Outpatient","1","EA","3.05","3.05","","","","3.05","Fee Schedule","","","","","3.05","Fee Schedule","","","","","3.05","Fee Schedule","","","52","","3.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","52","","","Percent of Total Billed Charges","neg_dollar:$1.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.58","52","","","Percent of Total Billed Charges","neg_dollar:$1.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","86","","","Percent of Total Billed Charges","neg_dollar:$2.62","2.13","70","","","Percent of Total Billed Charges","neg_dollar:$2.13","","52","","3.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.79;102% of Medicaid interim rate","2.28","75","","","Percent of Total Billed Charges","neg_dollar:$2.28","2.62","86","","","Percent of Total Billed Charges","neg_dollar:$2.62","2.13","70","","","Percent of Total Billed Charges","neg_dollar:$2.13","1.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.73;103.5% of Medicaid interim rate","3.05","150","","","Percent of Total Billed Charges","neg_dollar:$4.71;150% of Medicaid interim rate","2.44","80","","","Percent of Total Billed Charges","neg_dollar:$2.44;Percent of Total Billed Charges","2.80","92","","","Percent of Total Billed Charges","neg_dollar:$2.80","1.58","52","","","Percent of Total Billed Charges","neg_dollar:$1.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.05","Fee Schedule","","1.00","3.00",""
"AMITRIPTYLINE HCL 25 MG PO TABS","","","60687-433-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.55","Fee Schedule","","1.00","1.00",""
"CELECOXIB 100 MG PO CAPS","","","60687-436-11","NDC","250","RC","","Facility","Outpatient","100","ME","2.25","2.25","","","","2.25","Fee Schedule","","","","","2.25","Fee Schedule","","","","","2.25","Fee Schedule","","","52","","2.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.93","86","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","","52","","2.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% of Medicaid interim rate","1.68","75","","","Percent of Total Billed Charges","neg_dollar:$1.68","1.93","86","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.28;103.5% of Medicaid interim rate","2.25","150","","","Percent of Total Billed Charges","neg_dollar:$3.47;150% of Medicaid interim rate","1.80","80","","","Percent of Total Billed Charges","neg_dollar:$1.80;Percent of Total Billed Charges","2.07","92","","","Percent of Total Billed Charges","neg_dollar:$2.07","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.25","Fee Schedule","","1.00","2.00",""
"AMIODARONE HCL 200 MG PO TABS","","","60687-437-11","NDC","250","RC","","Facility","Outpatient","200","ME","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","","52","","1.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.45","Fee Schedule","","1.00","1.00",""
"IBUPROFEN 400 MG PO TABS","","","60687-446-11","NDC","250","RC","","Facility","Outpatient","400","ME","0.48","0.48","","","","0.48","Fee Schedule","","","","","0.48","Fee Schedule","","","","","0.48","Fee Schedule","","","52","","0.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.25","52","","","Percent of Total Billed Charges","neg_dollar:$0.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.25","52","","","Percent of Total Billed Charges","neg_dollar:$0.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","86","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.33","70","","","Percent of Total Billed Charges","neg_dollar:$0.33","","52","","0.48","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;102% of Medicaid interim rate","0.36","75","","","Percent of Total Billed Charges","neg_dollar:$0.36","0.41","86","","","Percent of Total Billed Charges","neg_dollar:$0.41","0.33","70","","","Percent of Total Billed Charges","neg_dollar:$0.33","0.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.27;103.5% of Medicaid interim rate","0.48","150","","","Percent of Total Billed Charges","neg_dollar:$0.74;150% of Medicaid interim rate","0.38","80","","","Percent of Total Billed Charges","neg_dollar:$0.38;Percent of Total Billed Charges","0.44","92","","","Percent of Total Billed Charges","neg_dollar:$0.44","0.25","52","","","Percent of Total Billed Charges","neg_dollar:$0.25;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.48","Fee Schedule","","1.00","1.00",""
"LEVOTHYROXINE SODIUM 50 MCG PO TABS","","","60687-464-11","NDC","250","RC","","Facility","Outpatient","50","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"SPIRONOLACTONE 25 MG PO TABS","","","60687-465-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.08","1.08","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","","","52","","1.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","","52","","1.08","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.93","86","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;103.5% of Medicaid interim rate","1.08","150","","","Percent of Total Billed Charges","neg_dollar:$1.67;150% of Medicaid interim rate","0.86","80","","","Percent of Total Billed Charges","neg_dollar:$0.86;Percent of Total Billed Charges","0.99","92","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.08","Fee Schedule","","1.00","1.00",""
"SPIRONOLACTONE 25 MG PO TABS","","","60687-465-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"GLIPIZIDE ER 2.5 MG PO TB24","","","60687-480-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.48","1.48","","","","1.48","Fee Schedule","","","","","1.48","Fee Schedule","","","","","1.48","Fee Schedule","","","52","","1.48","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","52","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","52","","","Percent of Total Billed Charges","neg_dollar:$0.77;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.27","86","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","","52","","1.48","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.87;102% of Medicaid interim rate","1.11","75","","","Percent of Total Billed Charges","neg_dollar:$1.11","1.27","86","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.84;103.5% of Medicaid interim rate","1.48","150","","","Percent of Total Billed Charges","neg_dollar:$2.29;150% of Medicaid interim rate","1.19","80","","","Percent of Total Billed Charges","neg_dollar:$1.19;Percent of Total Billed Charges","1.36","92","","","Percent of Total Billed Charges","neg_dollar:$1.36","0.77","52","","","Percent of Total Billed Charges","neg_dollar:$0.77;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.48","Fee Schedule","","1.00","1.00",""
"PREGABALIN 50 MG PO CAPS","","","60687-484-11","NDC","250","RC","","Facility","Outpatient","50","ME","2.01","2.01","","","","2.01","Fee Schedule","","","","","2.01","Fee Schedule","","","","","2.01","Fee Schedule","","","52","","2.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.73","86","","","Percent of Total Billed Charges","neg_dollar:$1.73","1.41","70","","","Percent of Total Billed Charges","neg_dollar:$1.41","","52","","2.01","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.18;102% of Medicaid interim rate","1.51","75","","","Percent of Total Billed Charges","neg_dollar:$1.51","1.73","86","","","Percent of Total Billed Charges","neg_dollar:$1.73","1.41","70","","","Percent of Total Billed Charges","neg_dollar:$1.41","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;103.5% of Medicaid interim rate","2.01","150","","","Percent of Total Billed Charges","neg_dollar:$3.11;150% of Medicaid interim rate","1.61","80","","","Percent of Total Billed Charges","neg_dollar:$1.61;Percent of Total Billed Charges","1.85","92","","","Percent of Total Billed Charges","neg_dollar:$1.85","1.04","52","","","Percent of Total Billed Charges","neg_dollar:$1.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.01","Fee Schedule","","1.00","2.00",""
"PREGABALIN 50 MG PO CAPS","","","60687-484-11","NDC","637","RC","","Facility","Outpatient","50","ME","1.87","1.87","","","","1.87","Fee Schedule","","","","","1.87","Fee Schedule","101% of Medicare Fee Schedule","","","","1.87","Fee Schedule","","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","86","","","Percent of Total Billed Charges","neg_dollar:$1.61","1.31","70","","","Percent of Total Billed Charges","neg_dollar:$1.31","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.10;102% of Medicaid interim rate","1.40","75","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.61","86","","","Percent of Total Billed Charges","neg_dollar:$1.61","1.31","70","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.06;103.5% of Medicaid interim rate","1.87","150","","","Percent of Total Billed Charges","neg_dollar:$2.89;150% of Medicaid interim rate","1.50","80","","","Percent of Total Billed Charges","neg_dollar:$1.50;Percent of Total Billed Charges","1.72","92","","","Percent of Total Billed Charges","neg_dollar:$1.72","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LEVOTHYROXINE SODIUM 88 MCG PO TABS","","","60687-486-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.70","1.70","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","","","1.70","Fee Schedule","","","52","","1.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","","52","","1.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;102% of Medicaid interim rate","1.27","75","","","Percent of Total Billed Charges","neg_dollar:$1.27","1.46","86","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.19","70","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;103.5% of Medicaid interim rate","1.70","150","","","Percent of Total Billed Charges","neg_dollar:$2.62;150% of Medicaid interim rate","1.36","80","","","Percent of Total Billed Charges","neg_dollar:$1.36;Percent of Total Billed Charges","1.56","92","","","Percent of Total Billed Charges","neg_dollar:$1.56","0.88","52","","","Percent of Total Billed Charges","neg_dollar:$0.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.70","Fee Schedule","","1.00","1.00",""
"NAPROXEN 500 MG PO TABS","","","60687-491-11","NDC","250","RC","","Facility","Outpatient","500","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"LEVOTHYROXINE SODIUM 100 MCG PO TABS","","","60687-497-11","NDC","250","RC","","Facility","Outpatient","100","EA","0.98","0.98","","","","0.98","Fee Schedule","","","","","0.98","Fee Schedule","","","","","0.98","Fee Schedule","","","52","","0.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.84","86","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.69","70","","","Percent of Total Billed Charges","neg_dollar:$0.69","","52","","0.98","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% of Medicaid interim rate","0.74","75","","","Percent of Total Billed Charges","neg_dollar:$0.74","0.84","86","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.69","70","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.56;103.5% of Medicaid interim rate","0.98","150","","","Percent of Total Billed Charges","neg_dollar:$1.52;150% of Medicaid interim rate","0.79","80","","","Percent of Total Billed Charges","neg_dollar:$0.79;Percent of Total Billed Charges","0.90","92","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.51","52","","","Percent of Total Billed Charges","neg_dollar:$0.51;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.98","Fee Schedule","","1.00","1.00",""
"METRONIDAZOLE 500 MG PO TABS","","","60687-550-01","NDC","250","RC","","Facility","Outpatient","500","ME","1.90","1.90","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","52","","1.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","","52","","1.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% of Medicaid interim rate","1.42","75","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;103.5% of Medicaid interim rate","1.90","150","","","Percent of Total Billed Charges","neg_dollar:$2.93;150% of Medicaid interim rate","1.52","80","","","Percent of Total Billed Charges","neg_dollar:$1.52;Percent of Total Billed Charges","1.74","92","","","Percent of Total Billed Charges","neg_dollar:$1.74","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.90","Fee Schedule","","1.00","1.00",""
"METRONIDAZOLE 500 MG PO TABS","","","60687-550-11","NDC","250","RC","","Facility","Outpatient","500","ME","1.90","1.90","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","","","1.90","Fee Schedule","","","52","","1.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","","52","","1.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;102% of Medicaid interim rate","1.42","75","","","Percent of Total Billed Charges","neg_dollar:$1.42","1.63","86","","","Percent of Total Billed Charges","neg_dollar:$1.63","1.32","70","","","Percent of Total Billed Charges","neg_dollar:$1.32","1.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.08;103.5% of Medicaid interim rate","1.90","150","","","Percent of Total Billed Charges","neg_dollar:$2.93;150% of Medicaid interim rate","1.52","80","","","Percent of Total Billed Charges","neg_dollar:$1.52;Percent of Total Billed Charges","1.74","92","","","Percent of Total Billed Charges","neg_dollar:$1.74","0.98","52","","","Percent of Total Billed Charges","neg_dollar:$0.98;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.90","Fee Schedule","","1.00","1.00",""
"CYCLOBENZAPRINE HCL 10 MG PO TABS","","","60687-558-01","NDC","250","RC","","Facility","Outpatient","10","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"CYCLOBENZAPRINE HCL 10 MG PO TABS","","","60687-558-11","NDC","637","RC","","Facility","Outpatient","10","ME","1.95","1.95","","","","1.95","Fee Schedule","","","","","1.95","Fee Schedule","101% of Medicare Fee Schedule","","","","1.95","Fee Schedule","","1.01","52","","","Percent of Total Billed Charges","neg_dollar:$1.01;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.67","86","","","Percent of Total Billed Charges","neg_dollar:$1.67","1.36","70","","","Percent of Total Billed Charges","neg_dollar:$1.36","1.01","52","","","Percent of Total Billed Charges","neg_dollar:$1.01;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.14;102% of Medicaid interim rate","1.46","75","","","Percent of Total Billed Charges","neg_dollar:$1.46","1.67","86","","","Percent of Total Billed Charges","neg_dollar:$1.67","1.36","70","","","Percent of Total Billed Charges","neg_dollar:$1.36","1.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.11;103.5% of Medicaid interim rate","1.95","150","","","Percent of Total Billed Charges","neg_dollar:$3.01;150% of Medicaid interim rate","1.56","80","","","Percent of Total Billed Charges","neg_dollar:$1.56;Percent of Total Billed Charges","1.79","92","","","Percent of Total Billed Charges","neg_dollar:$1.79","1.01","52","","","Percent of Total Billed Charges","neg_dollar:$1.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.01","52","","","Percent of Total Billed Charges","neg_dollar:$1.01;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CYCLOBENZAPRINE HCL 10 MG PO TABS","","","60687-558-11","NDC","250","RC","","Facility","Outpatient","10","ME","1.67","1.67","","","","1.67","Fee Schedule","","","","","1.67","Fee Schedule","","","","","1.67","Fee Schedule","","","52","","1.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.43","86","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","70","","","Percent of Total Billed Charges","neg_dollar:$1.16","","52","","1.67","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.98;102% of Medicaid interim rate","1.25","75","","","Percent of Total Billed Charges","neg_dollar:$1.25","1.43","86","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","70","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.95;103.5% of Medicaid interim rate","1.67","150","","","Percent of Total Billed Charges","neg_dollar:$2.58;150% of Medicaid interim rate","1.33","80","","","Percent of Total Billed Charges","neg_dollar:$1.33;Percent of Total Billed Charges","1.53","92","","","Percent of Total Billed Charges","neg_dollar:$1.53","0.86","52","","","Percent of Total Billed Charges","neg_dollar:$0.86;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.67","Fee Schedule","","1.00","1.00",""
"GABAPENTIN 100 MG PO CAPS","","","60687-580-11","NDC","250","RC","","Facility","Outpatient","100","ME","0.65","0.65","","","","0.65","Fee Schedule","","","","","0.65","Fee Schedule","","","","","0.65","Fee Schedule","","","52","","0.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","","52","","0.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.38;102% of Medicaid interim rate","0.48","75","","","Percent of Total Billed Charges","neg_dollar:$0.48","0.55","86","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","70","","","Percent of Total Billed Charges","neg_dollar:$0.45","0.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.37;103.5% of Medicaid interim rate","0.65","150","","","Percent of Total Billed Charges","neg_dollar:$1;150% of Medicaid interim rate","0.52","80","","","Percent of Total Billed Charges","neg_dollar:$0.52;Percent of Total Billed Charges","0.59","92","","","Percent of Total Billed Charges","neg_dollar:$0.59","0.33","52","","","Percent of Total Billed Charges","neg_dollar:$0.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.65","Fee Schedule","","1.00","1.00",""
"PANTOPRAZOLE SODIUM 20 MG PO TBEC","","","60687-585-11","NDC","250","RC","","Facility","Outpatient","20","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"PROPRANOLOL HCL 10 MG PO TABS","","","60687-587-11","NDC","250","RC","","Facility","Outpatient","10","ME","0.80","0.80","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","","","","","0.80","Fee Schedule","","","52","","0.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","","52","","0.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% of Medicaid interim rate","0.60","75","","","Percent of Total Billed Charges","neg_dollar:$0.60","0.68","86","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.55","70","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;103.5% of Medicaid interim rate","0.80","150","","","Percent of Total Billed Charges","neg_dollar:$1.23;150% of Medicaid interim rate","0.64","80","","","Percent of Total Billed Charges","neg_dollar:$0.64;Percent of Total Billed Charges","0.73","92","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.41","52","","","Percent of Total Billed Charges","neg_dollar:$0.41;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.80","Fee Schedule","","1.00","1.00",""
"ROPINIROLE HCL 1 MG PO TABS","","","60687-588-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"GABAPENTIN 300 MG PO CAPS","","","60687-591-11","NDC","637","RC","","Facility","Outpatient","300","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"GABAPENTIN 300 MG PO CAPS","","","60687-591-11","NDC","250","RC","","Facility","Outpatient","300","ME","0.75","0.75","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","","","","","0.75","Fee Schedule","","","52","","0.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","","52","","0.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;102% of Medicaid interim rate","0.56","75","","","Percent of Total Billed Charges","neg_dollar:$0.56","0.64","86","","","Percent of Total Billed Charges","neg_dollar:$0.64","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;103.5% of Medicaid interim rate","0.75","150","","","Percent of Total Billed Charges","neg_dollar:$1.15;150% of Medicaid interim rate","0.60","80","","","Percent of Total Billed Charges","neg_dollar:$0.60;Percent of Total Billed Charges","0.69","92","","","Percent of Total Billed Charges","neg_dollar:$0.69","0.39","52","","","Percent of Total Billed Charges","neg_dollar:$0.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.75","Fee Schedule","","1.00","1.00",""
"HYDROCHLOROTHIAZIDE 25 MG PO TABS","","","60687-593-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"HYDROCHLOROTHIAZIDE 25 MG PO TABS","","","60687-593-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS","","","60687-614-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS","","","60687-614-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.87","1.87","","","","1.87","Fee Schedule","","","","","1.87","Fee Schedule","","","","","1.87","Fee Schedule","","","52","","1.87","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.61","86","","","Percent of Total Billed Charges","neg_dollar:$1.61","1.31","70","","","Percent of Total Billed Charges","neg_dollar:$1.31","","52","","1.87","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.10;102% of Medicaid interim rate","1.40","75","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.61","86","","","Percent of Total Billed Charges","neg_dollar:$1.61","1.31","70","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.06","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.06;103.5% of Medicaid interim rate","1.87","150","","","Percent of Total Billed Charges","neg_dollar:$2.89;150% of Medicaid interim rate","1.50","80","","","Percent of Total Billed Charges","neg_dollar:$1.50;Percent of Total Billed Charges","1.72","92","","","Percent of Total Billed Charges","neg_dollar:$1.72","0.97","52","","","Percent of Total Billed Charges","neg_dollar:$0.97;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.87","Fee Schedule","","1.00","1.00",""
"SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS","","","60687-614-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","101% of Medicare Fee Schedule","","","","1.35","Fee Schedule","","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MORPHINE SULFATE 15 MG PO TABS","","","60687-617-11","NDC","250","RC","","Facility","Outpatient","1","EA","2.25","2.25","","","","2.25","Fee Schedule","","","","","2.25","Fee Schedule","","","","","2.25","Fee Schedule","","","52","","2.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.93","86","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","","52","","2.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.32;102% of Medicaid interim rate","1.68","75","","","Percent of Total Billed Charges","neg_dollar:$1.68","1.93","86","","","Percent of Total Billed Charges","neg_dollar:$1.93","1.57","70","","","Percent of Total Billed Charges","neg_dollar:$1.57","1.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.28;103.5% of Medicaid interim rate","2.25","150","","","Percent of Total Billed Charges","neg_dollar:$3.47;150% of Medicaid interim rate","1.80","80","","","Percent of Total Billed Charges","neg_dollar:$1.80;Percent of Total Billed Charges","2.07","92","","","Percent of Total Billed Charges","neg_dollar:$2.07","1.17","52","","","Percent of Total Billed Charges","neg_dollar:$1.17;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.25","Fee Schedule","","1.00","2.00",""
"SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG PO TABS","","","60687-622-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"LORAZEPAM 0.5 MG PO TABS","","","60687-627-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","","52","","1.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.20","Fee Schedule","","1.00","1.00",""
"LORAZEPAM 0.5 MG PO TABS","","","60687-627-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.12","1.12","","","","1.12","Fee Schedule","","","","","1.12","Fee Schedule","","","","","1.12","Fee Schedule","","","52","","1.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","","52","","1.12","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% of Medicaid interim rate","0.84","75","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.96","86","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.78","70","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;103.5% of Medicaid interim rate","1.12","150","","","Percent of Total Billed Charges","neg_dollar:$1.73;150% of Medicaid interim rate","0.89","80","","","Percent of Total Billed Charges","neg_dollar:$0.89;Percent of Total Billed Charges","1.03","92","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.58","52","","","Percent of Total Billed Charges","neg_dollar:$0.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.12","Fee Schedule","","1.00","1.00",""
"POTASSIUM CHLORIDE 20 MEQ/15ML (10%) PO SOLN","","","60687-628-71","NDC","250","RC","","Facility","Outpatient","1","UN","21.32","21.32","","","","21.32","Fee Schedule","","","","","21.32","Fee Schedule","","","","","21.32","Fee Schedule","","","52","","21.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.09","52","","","Percent of Total Billed Charges","neg_dollar:$11.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.09","52","","","Percent of Total Billed Charges","neg_dollar:$11.09;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.34","86","","","Percent of Total Billed Charges","neg_dollar:$18.34","14.92","70","","","Percent of Total Billed Charges","neg_dollar:$14.92","","52","","21.32","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","12.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.53;102% of Medicaid interim rate","15.99","75","","","Percent of Total Billed Charges","neg_dollar:$15.99","18.34","86","","","Percent of Total Billed Charges","neg_dollar:$18.34","14.92","70","","","Percent of Total Billed Charges","neg_dollar:$14.92","12.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.15;103.5% of Medicaid interim rate","21.32","150","","","Percent of Total Billed Charges","neg_dollar:$32.97;150% of Medicaid interim rate","17.06","80","","","Percent of Total Billed Charges","neg_dollar:$17.06;Percent of Total Billed Charges","19.62","92","","","Percent of Total Billed Charges","neg_dollar:$19.62","11.09","52","","","Percent of Total Billed Charges","neg_dollar:$11.09;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","21.32","Fee Schedule","","11.00","21.00",""
"NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS","","","60687-633-11","NDC","250","RC","","Facility","Outpatient","100","ME","4.04","4.04","","","","4.04","Fee Schedule","","","","","4.04","Fee Schedule","","","","","4.04","Fee Schedule","","","52","","4.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.47","86","","","Percent of Total Billed Charges","neg_dollar:$3.47","2.82","70","","","Percent of Total Billed Charges","neg_dollar:$2.82","","52","","4.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.37;102% of Medicaid interim rate","3.03","75","","","Percent of Total Billed Charges","neg_dollar:$3.03","3.47","86","","","Percent of Total Billed Charges","neg_dollar:$3.47","2.82","70","","","Percent of Total Billed Charges","neg_dollar:$2.82","2.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.30;103.5% of Medicaid interim rate","4.04","150","","","Percent of Total Billed Charges","neg_dollar:$6.24;150% of Medicaid interim rate","3.23","80","","","Percent of Total Billed Charges","neg_dollar:$3.23;Percent of Total Billed Charges","3.71","92","","","Percent of Total Billed Charges","neg_dollar:$3.71","2.10","52","","","Percent of Total Billed Charges","neg_dollar:$2.10;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.04","Fee Schedule","","2.00","4.00",""
"LISINOPRIL 5 MG PO TABS","","","60687-667-11","NDC","250","RC","","Facility","Outpatient","5","ME","0.74","0.74","","","","0.74","Fee Schedule","","","","","0.74","Fee Schedule","","","","","0.74","Fee Schedule","","","52","","0.74","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.38","52","","","Percent of Total Billed Charges","neg_dollar:$0.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.38","52","","","Percent of Total Billed Charges","neg_dollar:$0.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","86","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","","52","","0.74","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.43;102% of Medicaid interim rate","0.55","75","","","Percent of Total Billed Charges","neg_dollar:$0.55","0.63","86","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.52","70","","","Percent of Total Billed Charges","neg_dollar:$0.52","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;103.5% of Medicaid interim rate","0.74","150","","","Percent of Total Billed Charges","neg_dollar:$1.14;150% of Medicaid interim rate","0.59","80","","","Percent of Total Billed Charges","neg_dollar:$0.59;Percent of Total Billed Charges","0.68","92","","","Percent of Total Billed Charges","neg_dollar:$0.68","0.38","52","","","Percent of Total Billed Charges","neg_dollar:$0.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.74","Fee Schedule","","1.00","1.00",""
"HYDROXYZINE HCL 25 MG PO TABS","","","60687-675-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.01","1.01","","","","1.01","Fee Schedule","","","","","1.01","Fee Schedule","","","","","1.01","Fee Schedule","","","52","","1.01","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.87","86","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","70","","","Percent of Total Billed Charges","neg_dollar:$0.71","","52","","1.01","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% of Medicaid interim rate","0.76","75","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.87","86","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","70","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.57;103.5% of Medicaid interim rate","1.01","150","","","Percent of Total Billed Charges","neg_dollar:$1.56;150% of Medicaid interim rate","0.81","80","","","Percent of Total Billed Charges","neg_dollar:$0.81;Percent of Total Billed Charges","0.93","92","","","Percent of Total Billed Charges","neg_dollar:$0.93","0.52","52","","","Percent of Total Billed Charges","neg_dollar:$0.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.01","Fee Schedule","","1.00","1.00",""
"FOLIC ACID 1 MG PO TABS","","","60687-681-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"CEFDINIR 300 MG PO CAPS","","","60687-699-11","NDC","250","RC","","Facility","Outpatient","300","ME","5.05","5.05","","","","5.05","Fee Schedule","","","","","5.05","Fee Schedule","","","","","5.05","Fee Schedule","","","52","","5.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","","52","","5.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.96;102% of Medicaid interim rate","3.78","75","","","Percent of Total Billed Charges","neg_dollar:$3.78","4.34","86","","","Percent of Total Billed Charges","neg_dollar:$4.34","3.53","70","","","Percent of Total Billed Charges","neg_dollar:$3.53","2.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.87;103.5% of Medicaid interim rate","5.05","150","","","Percent of Total Billed Charges","neg_dollar:$7.80;150% of Medicaid interim rate","4.04","80","","","Percent of Total Billed Charges","neg_dollar:$4.04;Percent of Total Billed Charges","4.64","92","","","Percent of Total Billed Charges","neg_dollar:$4.64","2.62","52","","","Percent of Total Billed Charges","neg_dollar:$2.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.05","Fee Schedule","","2.00","5.00",""
"MECLIZINE HCL 25 MG PO TABS","","","60687-730-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","","52","","1.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.75","Fee Schedule","","1.00","1.00",""
"MECLIZINE HCL 25 MG PO TABS","","","60687-730-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","101% of Medicare Fee Schedule","","","","1.75","Fee Schedule","","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"SUCRALFATE 1 GM/10ML PO SUSP","","","60687-738-56","NDC","250","RC","","Facility","Outpatient","1","GM","20.50","20.50","","","","20.50","Fee Schedule","","","","","20.50","Fee Schedule","","","","","20.50","Fee Schedule","","","52","","20.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.66","52","","","Percent of Total Billed Charges","neg_dollar:$10.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.66","52","","","Percent of Total Billed Charges","neg_dollar:$10.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.63","86","","","Percent of Total Billed Charges","neg_dollar:$17.63","14.35","70","","","Percent of Total Billed Charges","neg_dollar:$14.35","","52","","20.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","12.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.04;102% of Medicaid interim rate","15.37","75","","","Percent of Total Billed Charges","neg_dollar:$15.37","17.63","86","","","Percent of Total Billed Charges","neg_dollar:$17.63","14.35","70","","","Percent of Total Billed Charges","neg_dollar:$14.35","11.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.68;103.5% of Medicaid interim rate","20.50","150","","","Percent of Total Billed Charges","neg_dollar:$31.69;150% of Medicaid interim rate","16.40","80","","","Percent of Total Billed Charges","neg_dollar:$16.40;Percent of Total Billed Charges","18.86","92","","","Percent of Total Billed Charges","neg_dollar:$18.86","10.66","52","","","Percent of Total Billed Charges","neg_dollar:$10.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","20.50","Fee Schedule","","10.00","20.00",""
"BUPROPION HCL ER (XL) 150 MG PO TB24","","","60687-782-11","NDC","250","RC","","Facility","Outpatient","1","EA","3.25","3.25","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","","","52","","3.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","","52","","3.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.90;102% of Medicaid interim rate","2.43","75","","","Percent of Total Billed Charges","neg_dollar:$2.43","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.85;103.5% of Medicaid interim rate","3.25","150","","","Percent of Total Billed Charges","neg_dollar:$5.02;150% of Medicaid interim rate","2.60","80","","","Percent of Total Billed Charges","neg_dollar:$2.60;Percent of Total Billed Charges","2.99","92","","","Percent of Total Billed Charges","neg_dollar:$2.99","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.25","Fee Schedule","","1.00","3.00",""
"TRAMADOL HCL 50 MG PO TABS","","","60687-795-11","NDC","250","RC","","Facility","Outpatient","50","ME","1.24","1.24","","","","1.24","Fee Schedule","","","","","1.24","Fee Schedule","","","","","1.24","Fee Schedule","","","52","","1.24","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","52","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","52","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","86","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.24","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.06","86","","","Percent of Total Billed Charges","neg_dollar:$1.06","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;103.5% of Medicaid interim rate","1.24","150","","","Percent of Total Billed Charges","neg_dollar:$1.92;150% of Medicaid interim rate","0.99","80","","","Percent of Total Billed Charges","neg_dollar:$0.99;Percent of Total Billed Charges","1.14","92","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.64","52","","","Percent of Total Billed Charges","neg_dollar:$0.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.24","Fee Schedule","","1.00","1.00",""
"TRAMADOL HCL 50 MG PO TABS","","","60687-795-11","NDC","637","RC","","Facility","Outpatient","50","ME","1.20","1.20","","","","1.20","Fee Schedule","","","","","1.20","Fee Schedule","101% of Medicare Fee Schedule","","","","1.20","Fee Schedule","","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.03","86","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","70","","","Percent of Total Billed Charges","neg_dollar:$0.84","0.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.68;103.5% of Medicaid interim rate","1.20","150","","","Percent of Total Billed Charges","neg_dollar:$1.85;150% of Medicaid interim rate","0.96","80","","","Percent of Total Billed Charges","neg_dollar:$0.96;Percent of Total Billed Charges","1.10","92","","","Percent of Total Billed Charges","neg_dollar:$1.10","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","52","","","Percent of Total Billed Charges","neg_dollar:$0.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","","","60687-803-11","NDC","250","RC","","Facility","Outpatient","1","EA","8.65","8.65","","","","8.65","Fee Schedule","","","","","8.65","Fee Schedule","","","","","8.65","Fee Schedule","","","52","","8.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","4.49","52","","","Percent of Total Billed Charges","neg_dollar:$4.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.49","52","","","Percent of Total Billed Charges","neg_dollar:$4.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","7.43","86","","","Percent of Total Billed Charges","neg_dollar:$7.43","6.05","70","","","Percent of Total Billed Charges","neg_dollar:$6.05","","52","","8.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.08;102% of Medicaid interim rate","6.48","75","","","Percent of Total Billed Charges","neg_dollar:$6.48","7.43","86","","","Percent of Total Billed Charges","neg_dollar:$7.43","6.05","70","","","Percent of Total Billed Charges","neg_dollar:$6.05","4.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.93;103.5% of Medicaid interim rate","8.65","150","","","Percent of Total Billed Charges","neg_dollar:$13.37;150% of Medicaid interim rate","6.92","80","","","Percent of Total Billed Charges","neg_dollar:$6.92;Percent of Total Billed Charges","7.95","92","","","Percent of Total Billed Charges","neg_dollar:$7.95","4.49","52","","","Percent of Total Billed Charges","neg_dollar:$4.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","8.65","Fee Schedule","","4.00","8.00",""
"HYDRALAZINE HCL 25 MG PO TABS","","","60687-822-11","NDC","637","RC","","Facility","Outpatient","25","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HYDRALAZINE HCL 25 MG PO TABS","","","60687-822-11","NDC","250","RC","","Facility","Outpatient","25","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"PREDNISOLONE ACETATE 1 % OP SUSP","","","60758-119-05","NDC","250","RC","","Facility","Outpatient","1","EA","58.90","58.90","","","","58.90","Fee Schedule","","","","","58.90","Fee Schedule","","","","","58.90","Fee Schedule","","","52","","58.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","30.62","52","","","Percent of Total Billed Charges","neg_dollar:$30.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.62","52","","","Percent of Total Billed Charges","neg_dollar:$30.62;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.65","86","","","Percent of Total Billed Charges","neg_dollar:$50.65","41.23","70","","","Percent of Total Billed Charges","neg_dollar:$41.23","","52","","58.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","34.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.60;102% of Medicaid interim rate","44.17","75","","","Percent of Total Billed Charges","neg_dollar:$44.17","50.65","86","","","Percent of Total Billed Charges","neg_dollar:$50.65","41.23","70","","","Percent of Total Billed Charges","neg_dollar:$41.23","33.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.57;103.5% of Medicaid interim rate","58.90","150","","","Percent of Total Billed Charges","neg_dollar:$91.06;150% of Medicaid interim rate","47.12","80","","","Percent of Total Billed Charges","neg_dollar:$47.12;Percent of Total Billed Charges","54.18","92","","","Percent of Total Billed Charges","neg_dollar:$54.18","30.62","52","","","Percent of Total Billed Charges","neg_dollar:$30.62;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","58.90","Fee Schedule","","30.00","58.00",""
"KETOROLAC TROMETHAMINE 0.5 % OP SOLN","","","61314-126-05","NDC","250","RC","","Facility","Outpatient","1","UN","41.30","41.30","","","","41.30","Fee Schedule","","","","","41.30","Fee Schedule","","","","","41.30","Fee Schedule","","","52","","41.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","21.47","52","","","Percent of Total Billed Charges","neg_dollar:$21.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","21.47","52","","","Percent of Total Billed Charges","neg_dollar:$21.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","35.51","86","","","Percent of Total Billed Charges","neg_dollar:$35.51","28.90","70","","","Percent of Total Billed Charges","neg_dollar:$28.90","","52","","41.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","24.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$24.26;102% of Medicaid interim rate","30.97","75","","","Percent of Total Billed Charges","neg_dollar:$30.97","35.51","86","","","Percent of Total Billed Charges","neg_dollar:$35.51","28.90","70","","","Percent of Total Billed Charges","neg_dollar:$28.90","23.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$23.54;103.5% of Medicaid interim rate","41.30","150","","","Percent of Total Billed Charges","neg_dollar:$63.85;150% of Medicaid interim rate","33.04","80","","","Percent of Total Billed Charges","neg_dollar:$33.04;Percent of Total Billed Charges","37.99","92","","","Percent of Total Billed Charges","neg_dollar:$37.99","21.47","52","","","Percent of Total Billed Charges","neg_dollar:$21.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","41.30","Fee Schedule","","21.00","41.00",""
"LATANOPROST 0.005 % OP SOLN","","","61314-547-01","NDC","250","RC","","Facility","Outpatient","1","UN","22.30","22.30","","","","22.30","Fee Schedule","","","","","22.30","Fee Schedule","","","","","22.30","Fee Schedule","","","52","","22.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.17","86","","","Percent of Total Billed Charges","neg_dollar:$19.17","15.61","70","","","Percent of Total Billed Charges","neg_dollar:$15.61","","52","","22.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","13.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$13.10;102% of Medicaid interim rate","16.72","75","","","Percent of Total Billed Charges","neg_dollar:$16.72","19.17","86","","","Percent of Total Billed Charges","neg_dollar:$19.17","15.61","70","","","Percent of Total Billed Charges","neg_dollar:$15.61","12.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.71;103.5% of Medicaid interim rate","22.30","150","","","Percent of Total Billed Charges","neg_dollar:$34.47;150% of Medicaid interim rate","17.84","80","","","Percent of Total Billed Charges","neg_dollar:$17.84;Percent of Total Billed Charges","20.51","92","","","Percent of Total Billed Charges","neg_dollar:$20.51","11.59","52","","","Percent of Total Billed Charges","neg_dollar:$11.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","22.30","Fee Schedule","","11.00","22.00",""
"POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN","","","61314-628-10","NDC","250","RC","","Facility","Outpatient","1","UN","21.90","21.90","","","","21.90","Fee Schedule","","","","","21.90","Fee Schedule","","","","","21.90","Fee Schedule","","","52","","21.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.38","52","","","Percent of Total Billed Charges","neg_dollar:$11.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.38","52","","","Percent of Total Billed Charges","neg_dollar:$11.38;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.83","86","","","Percent of Total Billed Charges","neg_dollar:$18.83","15.32","70","","","Percent of Total Billed Charges","neg_dollar:$15.32","","52","","21.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","12.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.86;102% of Medicaid interim rate","16.42","75","","","Percent of Total Billed Charges","neg_dollar:$16.42","18.83","86","","","Percent of Total Billed Charges","neg_dollar:$18.83","15.32","70","","","Percent of Total Billed Charges","neg_dollar:$15.32","12.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.48;103.5% of Medicaid interim rate","21.90","150","","","Percent of Total Billed Charges","neg_dollar:$33.85;150% of Medicaid interim rate","17.52","80","","","Percent of Total Billed Charges","neg_dollar:$17.52;Percent of Total Billed Charges","20.14","92","","","Percent of Total Billed Charges","neg_dollar:$20.14","11.38","52","","","Percent of Total Billed Charges","neg_dollar:$11.38;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","21.90","Fee Schedule","","11.00","21.00",""
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT","","","61314-631-36","NDC","250","RC","","Facility","Outpatient","1","EA","30.35","30.35","","","","30.35","Fee Schedule","","","","","30.35","Fee Schedule","","","","","30.35","Fee Schedule","","","52","","30.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","15.78","52","","","Percent of Total Billed Charges","neg_dollar:$15.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.78","52","","","Percent of Total Billed Charges","neg_dollar:$15.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","26.10","86","","","Percent of Total Billed Charges","neg_dollar:$26.10","21.24","70","","","Percent of Total Billed Charges","neg_dollar:$21.24","","52","","30.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","17.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.83;102% of Medicaid interim rate","22.76","75","","","Percent of Total Billed Charges","neg_dollar:$22.76","26.10","86","","","Percent of Total Billed Charges","neg_dollar:$26.10","21.24","70","","","Percent of Total Billed Charges","neg_dollar:$21.24","17.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$17.29;103.5% of Medicaid interim rate","30.35","150","","","Percent of Total Billed Charges","neg_dollar:$46.92;150% of Medicaid interim rate","24.28","80","","","Percent of Total Billed Charges","neg_dollar:$24.28;Percent of Total Billed Charges","27.92","92","","","Percent of Total Billed Charges","neg_dollar:$27.92","15.78","52","","","Percent of Total Billed Charges","neg_dollar:$15.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","30.35","Fee Schedule","","15.00","30.00",""
"PREDNISOLONE ACETATE 1 % OP SUSP","","","61314-637-05","NDC","250","RC","","Facility","Outpatient","1","EA","59.20","59.20","","","","59.20","Fee Schedule","","","","","59.20","Fee Schedule","","","","","59.20","Fee Schedule","","","52","","59.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","30.78","52","","","Percent of Total Billed Charges","neg_dollar:$30.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.78","52","","","Percent of Total Billed Charges","neg_dollar:$30.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.91","86","","","Percent of Total Billed Charges","neg_dollar:$50.91","41.44","70","","","Percent of Total Billed Charges","neg_dollar:$41.44","","52","","59.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","34.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.77;102% of Medicaid interim rate","44.40","75","","","Percent of Total Billed Charges","neg_dollar:$44.40","50.91","86","","","Percent of Total Billed Charges","neg_dollar:$50.91","41.44","70","","","Percent of Total Billed Charges","neg_dollar:$41.44","33.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.74;103.5% of Medicaid interim rate","59.20","150","","","Percent of Total Billed Charges","neg_dollar:$91.52;150% of Medicaid interim rate","47.36","80","","","Percent of Total Billed Charges","neg_dollar:$47.36;Percent of Total Billed Charges","54.46","92","","","Percent of Total Billed Charges","neg_dollar:$54.46","30.78","52","","","Percent of Total Billed Charges","neg_dollar:$30.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","59.20","Fee Schedule","","30.00","59.00",""
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS","","","62559-490-01","NDC","250","RC","","Facility","Outpatient","1","EA","0.72","0.72","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","52","","0.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","","52","","0.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% of Medicaid interim rate","0.54","75","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.41;103.5% of Medicaid interim rate","0.72","150","","","Percent of Total Billed Charges","neg_dollar:$1.12;150% of Medicaid interim rate","0.58","80","","","Percent of Total Billed Charges","neg_dollar:$0.58;Percent of Total Billed Charges","0.66","92","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.72","Fee Schedule","","1.00","1.00",""
"DOXYCYCLINE HYCLATE 100 MG PO TABS","","","62584-693-11","NDC","637","RC","","Facility","Outpatient","100","ME","10.17","10.17","","","","10.17","Fee Schedule","","","","","10.17","Fee Schedule","101% of Medicare Fee Schedule","","","","10.17","Fee Schedule","","5.29","52","","","Percent of Total Billed Charges","neg_dollar:$5.29;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.17","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","10.17","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.75","86","","","Percent of Total Billed Charges","neg_dollar:$8.75","7.12","70","","","Percent of Total Billed Charges","neg_dollar:$7.12","5.29","52","","","Percent of Total Billed Charges","neg_dollar:$5.29;105% Medicare Outpatient Cost to Charge Ratio of 52%","5.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.97;102% of Medicaid interim rate","7.63","75","","","Percent of Total Billed Charges","neg_dollar:$7.63","8.75","86","","","Percent of Total Billed Charges","neg_dollar:$8.75","7.12","70","","","Percent of Total Billed Charges","neg_dollar:$7.12","5.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.79;103.5% of Medicaid interim rate","10.17","150","","","Percent of Total Billed Charges","neg_dollar:$15.73;150% of Medicaid interim rate","8.14","80","","","Percent of Total Billed Charges","neg_dollar:$8.14;Percent of Total Billed Charges","9.36","92","","","Percent of Total Billed Charges","neg_dollar:$9.36","5.29","52","","","Percent of Total Billed Charges","neg_dollar:$5.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.29","52","","","Percent of Total Billed Charges","neg_dollar:$5.29;100% Medicare Outpatient Cost to Charge Ratio of 52%","5.00","10.00",""
"DOXYCYCLINE HYCLATE 100 MG PO TABS","","","62584-693-11","NDC","250","RC","","Facility","Outpatient","100","ME","5.54","5.54","","","","5.54","Fee Schedule","","","","","5.54","Fee Schedule","","","","","5.54","Fee Schedule","","","52","","5.54","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","4.76","86","","","Percent of Total Billed Charges","neg_dollar:$4.76","3.87","70","","","Percent of Total Billed Charges","neg_dollar:$3.87","","52","","5.54","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.25","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.25;102% of Medicaid interim rate","4.15","75","","","Percent of Total Billed Charges","neg_dollar:$4.15","4.76","86","","","Percent of Total Billed Charges","neg_dollar:$4.76","3.87","70","","","Percent of Total Billed Charges","neg_dollar:$3.87","3.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.15;103.5% of Medicaid interim rate","5.54","150","","","Percent of Total Billed Charges","neg_dollar:$8.56;150% of Medicaid interim rate","4.43","80","","","Percent of Total Billed Charges","neg_dollar:$4.43;Percent of Total Billed Charges","5.09","92","","","Percent of Total Billed Charges","neg_dollar:$5.09","2.88","52","","","Percent of Total Billed Charges","neg_dollar:$2.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","5.54","Fee Schedule","","2.00","5.00",""
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN","","","63323-462-37","NDC","250","RC","","Facility","Outpatient","1","EA","96.65","96.65","","","","96.65","Fee Schedule","","","","","96.65","Fee Schedule","","","","","96.65","Fee Schedule","","","52","","96.65","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","50.25","52","","","Percent of Total Billed Charges","neg_dollar:$50.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.25","52","","","Percent of Total Billed Charges","neg_dollar:$50.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","83.11","86","","","Percent of Total Billed Charges","neg_dollar:$83.11","67.65","70","","","Percent of Total Billed Charges","neg_dollar:$67.65","","52","","96.65","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","56.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.78;102% of Medicaid interim rate","72.48","75","","","Percent of Total Billed Charges","neg_dollar:$72.48","83.11","86","","","Percent of Total Billed Charges","neg_dollar:$83.11","67.65","70","","","Percent of Total Billed Charges","neg_dollar:$67.65","55.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$55.09;103.5% of Medicaid interim rate","96.65","150","","","Percent of Total Billed Charges","neg_dollar:$149.42;150% of Medicaid interim rate","77.32","80","","","Percent of Total Billed Charges","neg_dollar:$77.32;Percent of Total Billed Charges","88.91","92","","","Percent of Total Billed Charges","neg_dollar:$88.91","50.25","52","","","Percent of Total Billed Charges","neg_dollar:$50.25;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","96.65","Fee Schedule","","50.00","96.00",""
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","","","63323-482-27","NDC","250","RC","","Facility","Outpatient","1","UN","3.32","3.32","","","","3.32","Fee Schedule","","","","","3.32","Fee Schedule","","","","","3.32","Fee Schedule","","","52","","3.32","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","52","","","Percent of Total Billed Charges","neg_dollar:$1.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.72","52","","","Percent of Total Billed Charges","neg_dollar:$1.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.85","86","","","Percent of Total Billed Charges","neg_dollar:$2.85","2.32","70","","","Percent of Total Billed Charges","neg_dollar:$2.32","","52","","3.32","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.95;102% of Medicaid interim rate","2.49","75","","","Percent of Total Billed Charges","neg_dollar:$2.49","2.85","86","","","Percent of Total Billed Charges","neg_dollar:$2.85","2.32","70","","","Percent of Total Billed Charges","neg_dollar:$2.32","1.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.89;103.5% of Medicaid interim rate","3.32","150","","","Percent of Total Billed Charges","neg_dollar:$5.14;150% of Medicaid interim rate","2.66","80","","","Percent of Total Billed Charges","neg_dollar:$2.66;Percent of Total Billed Charges","3.05","92","","","Percent of Total Billed Charges","neg_dollar:$3.05","1.72","52","","","Percent of Total Billed Charges","neg_dollar:$1.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.32","Fee Schedule","","1.00","3.00",""
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN","","","63323-482-27","NDC","250","RC","","Facility","Outpatient","1","UN","90.81","90.81","","","","90.81","Fee Schedule","","","","","90.81","Fee Schedule","","","","","90.81","Fee Schedule","","","52","","90.81","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.22","52","","","Percent of Total Billed Charges","neg_dollar:$47.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.22","52","","","Percent of Total Billed Charges","neg_dollar:$47.22;102% Medicare Outpatient Cost to Charge Ratio of 52%","78.10","86","","","Percent of Total Billed Charges","neg_dollar:$78.10","63.57","70","","","Percent of Total Billed Charges","neg_dollar:$63.57","","52","","90.81","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","53.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$53.35;102% of Medicaid interim rate","68.11","75","","","Percent of Total Billed Charges","neg_dollar:$68.11","78.10","86","","","Percent of Total Billed Charges","neg_dollar:$78.10","63.57","70","","","Percent of Total Billed Charges","neg_dollar:$63.57","51.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$51.76;103.5% of Medicaid interim rate","90.81","150","","","Percent of Total Billed Charges","neg_dollar:$140.40;150% of Medicaid interim rate","72.65","80","","","Percent of Total Billed Charges","neg_dollar:$72.65;Percent of Total Billed Charges","83.55","92","","","Percent of Total Billed Charges","neg_dollar:$83.55","47.22","52","","","Percent of Total Billed Charges","neg_dollar:$47.22;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","90.81","Fee Schedule","","47.00","90.00",""
"ACETYLCYSTEINE 20 % IN SOLN","","","63323-694-04","NDC","250","RC","","Facility","Outpatient","1","UN","7.55","7.55","","","","7.55","Fee Schedule","","","","","7.55","Fee Schedule","","","","","7.55","Fee Schedule","","","52","","7.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.92","52","","","Percent of Total Billed Charges","neg_dollar:$3.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.92","52","","","Percent of Total Billed Charges","neg_dollar:$3.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.49","86","","","Percent of Total Billed Charges","neg_dollar:$6.49","5.28","70","","","Percent of Total Billed Charges","neg_dollar:$5.28","","52","","7.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","4.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.43;102% of Medicaid interim rate","5.66","75","","","Percent of Total Billed Charges","neg_dollar:$5.66","6.49","86","","","Percent of Total Billed Charges","neg_dollar:$6.49","5.28","70","","","Percent of Total Billed Charges","neg_dollar:$5.28","4.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.30;103.5% of Medicaid interim rate","7.55","150","","","Percent of Total Billed Charges","neg_dollar:$11.67;150% of Medicaid interim rate","6.04","80","","","Percent of Total Billed Charges","neg_dollar:$6.04;Percent of Total Billed Charges","6.94","92","","","Percent of Total Billed Charges","neg_dollar:$6.94","3.92","52","","","Percent of Total Billed Charges","neg_dollar:$3.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","7.55","Fee Schedule","","3.00","7.00",""
"ACETYLCYSTEINE 20 % IN SOLN","","","63323-694-41","NDC","250","RC","","Facility","Outpatient","1","EA","6.25","6.25","","","","6.25","Fee Schedule","","","","","6.25","Fee Schedule","","","","","6.25","Fee Schedule","","","52","","6.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.25","52","","","Percent of Total Billed Charges","neg_dollar:$3.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.25","52","","","Percent of Total Billed Charges","neg_dollar:$3.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.37","86","","","Percent of Total Billed Charges","neg_dollar:$5.37","4.37","70","","","Percent of Total Billed Charges","neg_dollar:$4.37","","52","","6.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","3.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.67;102% of Medicaid interim rate","4.68","75","","","Percent of Total Billed Charges","neg_dollar:$4.68","5.37","86","","","Percent of Total Billed Charges","neg_dollar:$5.37","4.37","70","","","Percent of Total Billed Charges","neg_dollar:$4.37","3.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.56;103.5% of Medicaid interim rate","6.25","150","","","Percent of Total Billed Charges","neg_dollar:$9.66;150% of Medicaid interim rate","5.00","80","","","Percent of Total Billed Charges","neg_dollar:$5;Percent of Total Billed Charges","5.75","92","","","Percent of Total Billed Charges","neg_dollar:$5.75","3.25","52","","","Percent of Total Billed Charges","neg_dollar:$3.25;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","6.25","Fee Schedule","","3.00","6.00",""
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","","","63323-965-03","NDC","250","RC","","Facility","Outpatient","1","ML","46.37","46.37","","","","46.37","Fee Schedule","","","","","46.37","Fee Schedule","","","","","46.37","Fee Schedule","","","52","","46.37","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","24.11","52","","","Percent of Total Billed Charges","neg_dollar:$24.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","24.11","52","","","Percent of Total Billed Charges","neg_dollar:$24.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","39.88","86","","","Percent of Total Billed Charges","neg_dollar:$39.88","32.46","70","","","Percent of Total Billed Charges","neg_dollar:$32.46","","52","","46.37","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","27.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$27.24;102% of Medicaid interim rate","34.78","75","","","Percent of Total Billed Charges","neg_dollar:$34.78","39.88","86","","","Percent of Total Billed Charges","neg_dollar:$39.88","32.46","70","","","Percent of Total Billed Charges","neg_dollar:$32.46","26.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$26.43;103.5% of Medicaid interim rate","46.37","150","","","Percent of Total Billed Charges","neg_dollar:$71.69;150% of Medicaid interim rate","37.10","80","","","Percent of Total Billed Charges","neg_dollar:$37.10;Percent of Total Billed Charges","42.66","92","","","Percent of Total Billed Charges","neg_dollar:$42.66","24.11","52","","","Percent of Total Billed Charges","neg_dollar:$24.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","46.37","Fee Schedule","","24.00","46.00",""
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN","","","63323-965-10","NDC","250","RC","","Facility","Outpatient","1","ML","91.99","91.99","","","","91.99","Fee Schedule","","","","","91.99","Fee Schedule","","","","","91.99","Fee Schedule","","","52","","91.99","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","47.83","52","","","Percent of Total Billed Charges","neg_dollar:$47.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","47.83","52","","","Percent of Total Billed Charges","neg_dollar:$47.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","79.11","86","","","Percent of Total Billed Charges","neg_dollar:$79.11","64.39","70","","","Percent of Total Billed Charges","neg_dollar:$64.39","","52","","91.99","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","54.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.04;102% of Medicaid interim rate","68.99","75","","","Percent of Total Billed Charges","neg_dollar:$68.99","79.11","86","","","Percent of Total Billed Charges","neg_dollar:$79.11","64.39","70","","","Percent of Total Billed Charges","neg_dollar:$64.39","52.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.43;103.5% of Medicaid interim rate","91.99","150","","","Percent of Total Billed Charges","neg_dollar:$142.22;150% of Medicaid interim rate","73.59","80","","","Percent of Total Billed Charges","neg_dollar:$73.59;Percent of Total Billed Charges","84.63","92","","","Percent of Total Billed Charges","neg_dollar:$84.63","47.83","52","","","Percent of Total Billed Charges","neg_dollar:$47.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","91.99","Fee Schedule","","47.00","91.00",""
"AMIODARONE HCL 200 MG PO TABS","","","63739-051-10","NDC","250","RC","","Facility","Outpatient","200","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"AMIODARONE HCL 200 MG PO TABS","","","63739-051-10","NDC","637","RC","","Facility","Outpatient","200","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","101% of Medicare Fee Schedule","","","","1.30","Fee Schedule","","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ASPIRIN 81 MG PO TBEC","","","63739-212-02","NDC","250","RC","","Facility","Outpatient","81","ME","0.50","0.50","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","","","0.50","Fee Schedule","","","52","","0.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","","52","","0.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.29;102% of Medicaid interim rate","0.37","75","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.43","86","","","Percent of Total Billed Charges","neg_dollar:$0.43","0.35","70","","","Percent of Total Billed Charges","neg_dollar:$0.35","0.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.28;103.5% of Medicaid interim rate","0.50","150","","","Percent of Total Billed Charges","neg_dollar:$0.77;150% of Medicaid interim rate","0.40","80","","","Percent of Total Billed Charges","neg_dollar:$0.40;Percent of Total Billed Charges","0.46","92","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.26","52","","","Percent of Total Billed Charges","neg_dollar:$0.26;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.50","Fee Schedule","","1.00","1.00",""
"ASPIRIN LOW DOSE 81 MG PO CHEW","","","63739-434-02","NDC","250","RC","","Facility","Outpatient","81","ME","0.23","0.23","","","","0.23","Fee Schedule","","","","","0.23","Fee Schedule","","","","","0.23","Fee Schedule","","","52","","0.23","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.12","52","","","Percent of Total Billed Charges","neg_dollar:$0.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.12","52","","","Percent of Total Billed Charges","neg_dollar:$0.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.19","86","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.16","70","","","Percent of Total Billed Charges","neg_dollar:$0.16","","52","","0.23","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% of Medicaid interim rate","0.17","75","","","Percent of Total Billed Charges","neg_dollar:$0.17","0.19","86","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.16","70","","","Percent of Total Billed Charges","neg_dollar:$0.16","0.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.13;103.5% of Medicaid interim rate","0.23","150","","","Percent of Total Billed Charges","neg_dollar:$0.35;150% of Medicaid interim rate","0.18","80","","","Percent of Total Billed Charges","neg_dollar:$0.18;Percent of Total Billed Charges","0.21","92","","","Percent of Total Billed Charges","neg_dollar:$0.21","0.12","52","","","Percent of Total Billed Charges","neg_dollar:$0.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.23","Fee Schedule","","1.00","1.00",""
"ASPIRIN LOW DOSE 81 MG PO CHEW","","","63739-434-02","NDC","637","RC","","Facility","Outpatient","81","ME","0.12","0.12","","","","0.12","Fee Schedule","","","","","0.12","Fee Schedule","101% of Medicare Fee Schedule","","","","0.12","Fee Schedule","","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.12","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.10","86","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.08","70","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.07;102% of Medicaid interim rate","0.09","75","","","Percent of Total Billed Charges","neg_dollar:$0.09","0.10","86","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.08","70","","","Percent of Total Billed Charges","neg_dollar:$0.08","0.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.07;103.5% of Medicaid interim rate","0.12","150","","","Percent of Total Billed Charges","neg_dollar:$0.19;150% of Medicaid interim rate","0.10","80","","","Percent of Total Billed Charges","neg_dollar:$0.10;Percent of Total Billed Charges","0.11","92","","","Percent of Total Billed Charges","neg_dollar:$0.11","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.06","52","","","Percent of Total Billed Charges","neg_dollar:$0.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ASPIRIN LOW DOSE 81 MG PO CHEW","","","63739-434-02","NDC","637","RC","","Facility","Outpatient","81","ME","0.15","0.15","","","","0.15","Fee Schedule","","","","","0.15","Fee Schedule","101% of Medicare Fee Schedule","","","","0.15","Fee Schedule","","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","86","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.10","70","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.09;102% of Medicaid interim rate","0.11","75","","","Percent of Total Billed Charges","neg_dollar:$0.11","0.13","86","","","Percent of Total Billed Charges","neg_dollar:$0.13","0.10","70","","","Percent of Total Billed Charges","neg_dollar:$0.10","0.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.08;103.5% of Medicaid interim rate","0.15","150","","","Percent of Total Billed Charges","neg_dollar:$0.23;150% of Medicaid interim rate","0.12","80","","","Percent of Total Billed Charges","neg_dollar:$0.12;Percent of Total Billed Charges","0.14","92","","","Percent of Total Billed Charges","neg_dollar:$0.14","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.07","52","","","Percent of Total Billed Charges","neg_dollar:$0.07;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"HYDROXYZINE HCL 10 MG PO TABS","","","63739-483-10","NDC","250","RC","","Facility","Outpatient","10","ME","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"FAMOTIDINE 20 MG PO TABS","","","63739-645-10","NDC","250","RC","","Facility","Outpatient","20","ME","1.08","1.08","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","","","","","1.08","Fee Schedule","","","52","","1.08","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","","52","","1.08","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.63;102% of Medicaid interim rate","0.81","75","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.92","86","","","Percent of Total Billed Charges","neg_dollar:$0.92","0.75","70","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;103.5% of Medicaid interim rate","1.08","150","","","Percent of Total Billed Charges","neg_dollar:$1.66;150% of Medicaid interim rate","0.86","80","","","Percent of Total Billed Charges","neg_dollar:$0.86;Percent of Total Billed Charges","0.99","92","","","Percent of Total Billed Charges","neg_dollar:$0.99","0.56","52","","","Percent of Total Billed Charges","neg_dollar:$0.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.08","Fee Schedule","","1.00","1.00",""
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS","","","64380-799-01","NDC","250","RC","","Facility","Outpatient","75","ME","3.25","3.25","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","","","","","3.25","Fee Schedule","","","52","","3.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","","52","","3.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.90;102% of Medicaid interim rate","2.43","75","","","Percent of Total Billed Charges","neg_dollar:$2.43","2.79","86","","","Percent of Total Billed Charges","neg_dollar:$2.79","2.27","70","","","Percent of Total Billed Charges","neg_dollar:$2.27","1.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.85;103.5% of Medicaid interim rate","3.25","150","","","Percent of Total Billed Charges","neg_dollar:$5.02;150% of Medicaid interim rate","2.60","80","","","Percent of Total Billed Charges","neg_dollar:$2.60;Percent of Total Billed Charges","2.99","92","","","Percent of Total Billed Charges","neg_dollar:$2.99","1.69","52","","","Percent of Total Billed Charges","neg_dollar:$1.69;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.25","Fee Schedule","","1.00","3.00",""
"NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP","","","64980-448-01","NDC","250","RC","","Facility","Outpatient","1","EA","118.90","118.90","","","","118.90","Fee Schedule","","","","","118.90","Fee Schedule","","","","","118.90","Fee Schedule","","","52","","118.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","61.82","52","","","Percent of Total Billed Charges","neg_dollar:$61.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","61.82","52","","","Percent of Total Billed Charges","neg_dollar:$61.82;102% Medicare Outpatient Cost to Charge Ratio of 52%","102.25","86","","","Percent of Total Billed Charges","neg_dollar:$102.25","83.23","70","","","Percent of Total Billed Charges","neg_dollar:$83.23","","52","","118.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","69.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$69.85;102% of Medicaid interim rate","89.17","75","","","Percent of Total Billed Charges","neg_dollar:$89.17","102.25","86","","","Percent of Total Billed Charges","neg_dollar:$102.25","83.23","70","","","Percent of Total Billed Charges","neg_dollar:$83.23","67.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$67.77;103.5% of Medicaid interim rate","118.90","150","","","Percent of Total Billed Charges","neg_dollar:$183.82;150% of Medicaid interim rate","95.12","80","","","Percent of Total Billed Charges","neg_dollar:$95.12;Percent of Total Billed Charges","109.38","92","","","Percent of Total Billed Charges","neg_dollar:$109.38","61.82","52","","","Percent of Total Billed Charges","neg_dollar:$61.82;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","118.90","Fee Schedule","","61.00","118.00",""
"LIDOCAINE 5 % EX PTCH","","","65162-791-04","NDC","250","RC","","Facility","Outpatient","5","EA","3.70","3.70","","","","3.70","Fee Schedule","","","","","3.70","Fee Schedule","","","","","3.70","Fee Schedule","","","52","","3.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.92","52","","","Percent of Total Billed Charges","neg_dollar:$1.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.92","52","","","Percent of Total Billed Charges","neg_dollar:$1.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.18","86","","","Percent of Total Billed Charges","neg_dollar:$3.18","2.59","70","","","Percent of Total Billed Charges","neg_dollar:$2.59","","52","","3.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.17;102% of Medicaid interim rate","2.77","75","","","Percent of Total Billed Charges","neg_dollar:$2.77","3.18","86","","","Percent of Total Billed Charges","neg_dollar:$3.18","2.59","70","","","Percent of Total Billed Charges","neg_dollar:$2.59","2.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.10;103.5% of Medicaid interim rate","3.70","150","","","Percent of Total Billed Charges","neg_dollar:$5.72;150% of Medicaid interim rate","2.96","80","","","Percent of Total Billed Charges","neg_dollar:$2.96;Percent of Total Billed Charges","3.40","92","","","Percent of Total Billed Charges","neg_dollar:$3.40","1.92","52","","","Percent of Total Billed Charges","neg_dollar:$1.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.70","Fee Schedule","","1.00","3.00",""
"ETOMIDATE 2 MG/ML IV SOLN","","","65219-445-01","NDC","250","RC","","Facility","Outpatient","1","EA","58.17","58.17","","","","58.17","Fee Schedule","","","","","58.17","Fee Schedule","","","","","58.17","Fee Schedule","","","52","","58.17","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","30.24","52","","","Percent of Total Billed Charges","neg_dollar:$30.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.24","52","","","Percent of Total Billed Charges","neg_dollar:$30.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","50.02","86","","","Percent of Total Billed Charges","neg_dollar:$50.02","40.71","70","","","Percent of Total Billed Charges","neg_dollar:$40.71","","52","","58.17","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","34.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$34.17;102% of Medicaid interim rate","43.62","75","","","Percent of Total Billed Charges","neg_dollar:$43.62","50.02","86","","","Percent of Total Billed Charges","neg_dollar:$50.02","40.71","70","","","Percent of Total Billed Charges","neg_dollar:$40.71","33.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$33.15;103.5% of Medicaid interim rate","58.17","150","","","Percent of Total Billed Charges","neg_dollar:$89.93;150% of Medicaid interim rate","46.53","80","","","Percent of Total Billed Charges","neg_dollar:$46.53;Percent of Total Billed Charges","53.51","92","","","Percent of Total Billed Charges","neg_dollar:$53.51","30.24","52","","","Percent of Total Billed Charges","neg_dollar:$30.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","58.17","Fee Schedule","","30.00","58.00",""
"ETOMIDATE 2 MG/ML IV SOLN","","","65219-445-10","NDC","250","RC","","Facility","Outpatient","1","EA","3.30","3.30","","","","3.30","Fee Schedule","","","","","3.30","Fee Schedule","","","","","3.30","Fee Schedule","","","52","","3.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.71","52","","","Percent of Total Billed Charges","neg_dollar:$1.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.71","52","","","Percent of Total Billed Charges","neg_dollar:$1.71;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.83","86","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.30","70","","","Percent of Total Billed Charges","neg_dollar:$2.30","","52","","3.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.93;102% of Medicaid interim rate","2.47","75","","","Percent of Total Billed Charges","neg_dollar:$2.47","2.83","86","","","Percent of Total Billed Charges","neg_dollar:$2.83","2.30","70","","","Percent of Total Billed Charges","neg_dollar:$2.30","1.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.88;103.5% of Medicaid interim rate","3.30","150","","","Percent of Total Billed Charges","neg_dollar:$5.10;150% of Medicaid interim rate","2.64","80","","","Percent of Total Billed Charges","neg_dollar:$2.64;Percent of Total Billed Charges","3.03","92","","","Percent of Total Billed Charges","neg_dollar:$3.03","1.71","52","","","Percent of Total Billed Charges","neg_dollar:$1.71;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.30","Fee Schedule","","1.00","3.00",""
"ETOMIDATE 2 MG/ML IV SOLN","","","65219-445-10","NDC","250","RC","","Facility","Outpatient","1","EA","72.71","72.71","","","","72.71","Fee Schedule","","","","","72.71","Fee Schedule","","","","","72.71","Fee Schedule","","","52","","72.71","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","37.81","52","","","Percent of Total Billed Charges","neg_dollar:$37.81;102% Medicare Outpatient Cost to Charge Ratio of 52%","37.81","52","","","Percent of Total Billed Charges","neg_dollar:$37.81;102% Medicare Outpatient Cost to Charge Ratio of 52%","62.53","86","","","Percent of Total Billed Charges","neg_dollar:$62.53","50.89","70","","","Percent of Total Billed Charges","neg_dollar:$50.89","","52","","72.71","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","42.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$42.71;102% of Medicaid interim rate","54.53","75","","","Percent of Total Billed Charges","neg_dollar:$54.53","62.53","86","","","Percent of Total Billed Charges","neg_dollar:$62.53","50.89","70","","","Percent of Total Billed Charges","neg_dollar:$50.89","41.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$41.44;103.5% of Medicaid interim rate","72.71","150","","","Percent of Total Billed Charges","neg_dollar:$112.41;150% of Medicaid interim rate","58.17","80","","","Percent of Total Billed Charges","neg_dollar:$58.17;Percent of Total Billed Charges","66.89","92","","","Percent of Total Billed Charges","neg_dollar:$66.89","37.81","52","","","Percent of Total Billed Charges","neg_dollar:$37.81;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","72.71","Fee Schedule","","37.00","72.00",""
"AMOXICILLIN 400 MG/5ML PO SUSR","","","65862-071-75","NDC","250","RC","","Facility","Outpatient","1","UN","15.80","15.80","","","","15.80","Fee Schedule","","","","","15.80","Fee Schedule","","","","","15.80","Fee Schedule","","","52","","15.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.21","52","","","Percent of Total Billed Charges","neg_dollar:$8.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.21","52","","","Percent of Total Billed Charges","neg_dollar:$8.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","13.58","86","","","Percent of Total Billed Charges","neg_dollar:$13.58","11.06","70","","","Percent of Total Billed Charges","neg_dollar:$11.06","","52","","15.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.28;102% of Medicaid interim rate","11.85","75","","","Percent of Total Billed Charges","neg_dollar:$11.85","13.58","86","","","Percent of Total Billed Charges","neg_dollar:$13.58","11.06","70","","","Percent of Total Billed Charges","neg_dollar:$11.06","9.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$9;103.5% of Medicaid interim rate","15.80","150","","","Percent of Total Billed Charges","neg_dollar:$24.42;150% of Medicaid interim rate","12.64","80","","","Percent of Total Billed Charges","neg_dollar:$12.64;Percent of Total Billed Charges","14.53","92","","","Percent of Total Billed Charges","neg_dollar:$14.53","8.21","52","","","Percent of Total Billed Charges","neg_dollar:$8.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","15.80","Fee Schedule","","8.00","15.00",""
"CEFDINIR 250 MG/5ML PO SUSR","","","65862-219-60","NDC","250","RC","","Facility","Outpatient","1","UN","32.50","32.50","","","","32.50","Fee Schedule","","","","","32.50","Fee Schedule","","","","","32.50","Fee Schedule","","","52","","32.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.95","86","","","Percent of Total Billed Charges","neg_dollar:$27.95","22.75","70","","","Percent of Total Billed Charges","neg_dollar:$22.75","","52","","32.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","19.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$19.09;102% of Medicaid interim rate","24.37","75","","","Percent of Total Billed Charges","neg_dollar:$24.37","27.95","86","","","Percent of Total Billed Charges","neg_dollar:$27.95","22.75","70","","","Percent of Total Billed Charges","neg_dollar:$22.75","18.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.52;103.5% of Medicaid interim rate","32.50","150","","","Percent of Total Billed Charges","neg_dollar:$50.24;150% of Medicaid interim rate","26.00","80","","","Percent of Total Billed Charges","neg_dollar:$26;Percent of Total Billed Charges","29.90","92","","","Percent of Total Billed Charges","neg_dollar:$29.90","16.90","52","","","Percent of Total Billed Charges","neg_dollar:$16.90;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","32.50","Fee Schedule","","16.00","32.00",""
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","","","65862-503-20","NDC","250","RC","","Facility","Outpatient","1","EA","2.18","2.18","","","","2.18","Fee Schedule","","","","","2.18","Fee Schedule","","","","","2.18","Fee Schedule","","","52","","2.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.13","52","","","Percent of Total Billed Charges","neg_dollar:$1.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.13","52","","","Percent of Total Billed Charges","neg_dollar:$1.13;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.88","86","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.53","70","","","Percent of Total Billed Charges","neg_dollar:$1.53","","52","","2.18","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.28;102% of Medicaid interim rate","1.64","75","","","Percent of Total Billed Charges","neg_dollar:$1.64","1.88","86","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.53","70","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.24;103.5% of Medicaid interim rate","2.18","150","","","Percent of Total Billed Charges","neg_dollar:$3.38;150% of Medicaid interim rate","1.75","80","","","Percent of Total Billed Charges","neg_dollar:$1.75;Percent of Total Billed Charges","2.01","92","","","Percent of Total Billed Charges","neg_dollar:$2.01","1.13","52","","","Percent of Total Billed Charges","neg_dollar:$1.13;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.18","Fee Schedule","","1.00","2.00",""
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS","","","65862-503-20","NDC","637","RC","","Facility","Outpatient","1","EA","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","101% of Medicare Fee Schedule","","","","1.45","Fee Schedule","","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"FAMOTIDINE (PF) 20 MG/2ML IV SOLN","","","67457-433-00","NDC","250","RC","","Facility","Outpatient","2","ML","65.43","65.43","","","","65.43","Fee Schedule","","","","","65.43","Fee Schedule","","","","","65.43","Fee Schedule","","","52","","65.43","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","34.02","52","","","Percent of Total Billed Charges","neg_dollar:$34.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","34.02","52","","","Percent of Total Billed Charges","neg_dollar:$34.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","56.27","86","","","Percent of Total Billed Charges","neg_dollar:$56.27","45.80","70","","","Percent of Total Billed Charges","neg_dollar:$45.80","","52","","65.43","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","38.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$38.44;102% of Medicaid interim rate","49.07","75","","","Percent of Total Billed Charges","neg_dollar:$49.07","56.27","86","","","Percent of Total Billed Charges","neg_dollar:$56.27","45.80","70","","","Percent of Total Billed Charges","neg_dollar:$45.80","37.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$37.29;103.5% of Medicaid interim rate","65.43","150","","","Percent of Total Billed Charges","neg_dollar:$101.16;150% of Medicaid interim rate","52.34","80","","","Percent of Total Billed Charges","neg_dollar:$52.34;Percent of Total Billed Charges","60.20","92","","","Percent of Total Billed Charges","neg_dollar:$60.20","34.02","52","","","Percent of Total Billed Charges","neg_dollar:$34.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","65.43","Fee Schedule","","34.00","65.00",""
"FAMOTIDINE (PF) 20 MG/2ML IV SOLN","","","67457-433-22","NDC","250","RC","","Facility","Outpatient","2","ML","89.30","89.30","","","","89.30","Fee Schedule","","","","","89.30","Fee Schedule","","","","","89.30","Fee Schedule","","","52","","89.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.79","86","","","Percent of Total Billed Charges","neg_dollar:$76.79","62.50","70","","","Percent of Total Billed Charges","neg_dollar:$62.50","","52","","89.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","52.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$52.46;102% of Medicaid interim rate","66.97","75","","","Percent of Total Billed Charges","neg_dollar:$66.97","76.79","86","","","Percent of Total Billed Charges","neg_dollar:$76.79","62.50","70","","","Percent of Total Billed Charges","neg_dollar:$62.50","50.90","56.99","","","Percent of Total Billed Charges","neg_dollar:$50.90;103.5% of Medicaid interim rate","89.30","150","","","Percent of Total Billed Charges","neg_dollar:$138.06;150% of Medicaid interim rate","71.44","80","","","Percent of Total Billed Charges","neg_dollar:$71.44;Percent of Total Billed Charges","82.15","92","","","Percent of Total Billed Charges","neg_dollar:$82.15","46.43","52","","","Percent of Total Billed Charges","neg_dollar:$46.43;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","89.30","Fee Schedule","","46.00","89.00",""
"POLYETHYLENE GLYCOL 3350 PO POWD","","","68001-607-55","NDC","250","RC","","Facility","Outpatient","1","UN","16.55","16.55","","","","16.55","Fee Schedule","","","","","16.55","Fee Schedule","","","","","16.55","Fee Schedule","","","52","","16.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","8.60","52","","","Percent of Total Billed Charges","neg_dollar:$8.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.60","52","","","Percent of Total Billed Charges","neg_dollar:$8.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.23","86","","","Percent of Total Billed Charges","neg_dollar:$14.23","11.58","70","","","Percent of Total Billed Charges","neg_dollar:$11.58","","52","","16.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","9.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.72;102% of Medicaid interim rate","12.41","75","","","Percent of Total Billed Charges","neg_dollar:$12.41","14.23","86","","","Percent of Total Billed Charges","neg_dollar:$14.23","11.58","70","","","Percent of Total Billed Charges","neg_dollar:$11.58","9.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$9.43;103.5% of Medicaid interim rate","16.55","150","","","Percent of Total Billed Charges","neg_dollar:$25.58;150% of Medicaid interim rate","13.24","80","","","Percent of Total Billed Charges","neg_dollar:$13.24;Percent of Total Billed Charges","15.22","92","","","Percent of Total Billed Charges","neg_dollar:$15.22","8.60","52","","","Percent of Total Billed Charges","neg_dollar:$8.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","16.55","Fee Schedule","","8.00","16.00",""
"PAROXETINE HCL 20 MG PO TABS","","","68084-045-11","NDC","250","RC","","Facility","Outpatient","20","ME","1.40","1.40","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","","","1.40","Fee Schedule","","","52","","1.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","","52","","1.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;102% of Medicaid interim rate","1.04","75","","","Percent of Total Billed Charges","neg_dollar:$1.04","1.20","86","","","Percent of Total Billed Charges","neg_dollar:$1.20","0.97","70","","","Percent of Total Billed Charges","neg_dollar:$0.97","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;103.5% of Medicaid interim rate","1.40","150","","","Percent of Total Billed Charges","neg_dollar:$2.16;150% of Medicaid interim rate","1.11","80","","","Percent of Total Billed Charges","neg_dollar:$1.11;Percent of Total Billed Charges","1.28","92","","","Percent of Total Billed Charges","neg_dollar:$1.28","0.72","52","","","Percent of Total Billed Charges","neg_dollar:$0.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.40","Fee Schedule","","1.00","1.00",""
"ATORVASTATIN CALCIUM 10 MG PO TABS","","","68084-097-11","NDC","250","RC","","Facility","Outpatient","10","ME","1.04","1.04","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","","","1.04","Fee Schedule","","","52","","1.04","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","","52","","1.04","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.89","86","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","70","","","Percent of Total Billed Charges","neg_dollar:$0.72","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.04","150","","","Percent of Total Billed Charges","neg_dollar:$1.60;150% of Medicaid interim rate","0.83","80","","","Percent of Total Billed Charges","neg_dollar:$0.83;Percent of Total Billed Charges","0.95","92","","","Percent of Total Billed Charges","neg_dollar:$0.95","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.04","Fee Schedule","","1.00","1.00",""
"ATORVASTATIN CALCIUM 10 MG PO TABS","","","68084-097-11","NDC","637","RC","","Facility","Outpatient","10","ME","0.95","0.95","","","","0.95","Fee Schedule","","","","","0.95","Fee Schedule","101% of Medicare Fee Schedule","","","","0.95","Fee Schedule","","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.95","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.55;102% of Medicaid interim rate","0.71","75","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.81","86","","","Percent of Total Billed Charges","neg_dollar:$0.81","0.66","70","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.54;103.5% of Medicaid interim rate","0.95","150","","","Percent of Total Billed Charges","neg_dollar:$1.46;150% of Medicaid interim rate","0.76","80","","","Percent of Total Billed Charges","neg_dollar:$0.76;Percent of Total Billed Charges","0.87","92","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.49","52","","","Percent of Total Billed Charges","neg_dollar:$0.49;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"ATORVASTATIN CALCIUM 40 MG PO TABS","","","68084-099-01","NDC","250","RC","","Facility","Outpatient","40","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.55","Fee Schedule","","1.00","1.00",""
"ATORVASTATIN CALCIUM 40 MG PO TABS","","","68084-099-11","NDC","250","RC","","Facility","Outpatient","40","ME","1.51","1.51","","","","1.51","Fee Schedule","","","","","1.51","Fee Schedule","","","","","1.51","Fee Schedule","","","52","","1.51","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.30","86","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.05","70","","","Percent of Total Billed Charges","neg_dollar:$1.05","","52","","1.51","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.13","75","","","Percent of Total Billed Charges","neg_dollar:$1.13","1.30","86","","","Percent of Total Billed Charges","neg_dollar:$1.30","1.05","70","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.86;103.5% of Medicaid interim rate","1.51","150","","","Percent of Total Billed Charges","neg_dollar:$2.33;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.39","92","","","Percent of Total Billed Charges","neg_dollar:$1.39","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.51","Fee Schedule","","1.00","1.00",""
"ATORVASTATIN CALCIUM 40 MG PO TABS","","","68084-099-11","NDC","637","RC","","Facility","Outpatient","40","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","101% of Medicare Fee Schedule","","","","1.55","Fee Schedule","","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MIRTAZAPINE 15 MG PO TABS","","","68084-119-11","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"BENZONATATE 100 MG PO CAPS","","","68084-214-11","NDC","250","RC","","Facility","Outpatient","100","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","","52","","1.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.60","Fee Schedule","","1.00","1.00",""
"LORATADINE 10 MG PO TABS","","","68084-248-11","NDC","250","RC","","Facility","Outpatient","10","ME","1.35","1.35","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","","","1.35","Fee Schedule","","","52","","1.35","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","","52","","1.35","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.79;102% of Medicaid interim rate","1.01","75","","","Percent of Total Billed Charges","neg_dollar:$1.01","1.16","86","","","Percent of Total Billed Charges","neg_dollar:$1.16","0.94","70","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;103.5% of Medicaid interim rate","1.35","150","","","Percent of Total Billed Charges","neg_dollar:$2.08;150% of Medicaid interim rate","1.08","80","","","Percent of Total Billed Charges","neg_dollar:$1.08;Percent of Total Billed Charges","1.24","92","","","Percent of Total Billed Charges","neg_dollar:$1.24","0.70","52","","","Percent of Total Billed Charges","neg_dollar:$0.70;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.35","Fee Schedule","","1.00","1.00",""
"HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS","","","68084-269-11","NDC","250","RC","","Facility","Outpatient","200","ME","2.85","2.85","","","","2.85","Fee Schedule","","","","","2.85","Fee Schedule","","","","","2.85","Fee Schedule","","","52","","2.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.48","52","","","Percent of Total Billed Charges","neg_dollar:$1.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.48","52","","","Percent of Total Billed Charges","neg_dollar:$1.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.45","86","","","Percent of Total Billed Charges","neg_dollar:$2.45","1.99","70","","","Percent of Total Billed Charges","neg_dollar:$1.99","","52","","2.85","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.67;102% of Medicaid interim rate","2.13","75","","","Percent of Total Billed Charges","neg_dollar:$2.13","2.45","86","","","Percent of Total Billed Charges","neg_dollar:$2.45","1.99","70","","","Percent of Total Billed Charges","neg_dollar:$1.99","1.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.62;103.5% of Medicaid interim rate","2.85","150","","","Percent of Total Billed Charges","neg_dollar:$4.40;150% of Medicaid interim rate","2.28","80","","","Percent of Total Billed Charges","neg_dollar:$2.28;Percent of Total Billed Charges","2.62","92","","","Percent of Total Billed Charges","neg_dollar:$2.62","1.48","52","","","Percent of Total Billed Charges","neg_dollar:$1.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.85","Fee Schedule","","1.00","2.00",""
"RISPERIDONE 1 MG PO TABS","","","68084-272-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.02","1.02","","","","1.02","Fee Schedule","","","","","1.02","Fee Schedule","","","","","1.02","Fee Schedule","","","52","","1.02","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","86","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.71","70","","","Percent of Total Billed Charges","neg_dollar:$0.71","","52","","1.02","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.60;102% of Medicaid interim rate","0.76","75","","","Percent of Total Billed Charges","neg_dollar:$0.76","0.88","86","","","Percent of Total Billed Charges","neg_dollar:$0.88","0.71","70","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.58","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.58;103.5% of Medicaid interim rate","1.02","150","","","Percent of Total Billed Charges","neg_dollar:$1.58;150% of Medicaid interim rate","0.82","80","","","Percent of Total Billed Charges","neg_dollar:$0.82;Percent of Total Billed Charges","0.94","92","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.53","52","","","Percent of Total Billed Charges","neg_dollar:$0.53;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.02","Fee Schedule","","1.00","1.00",""
"TAMSULOSIN HCL 0.4 MG PO CAPS","","","68084-299-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","","52","","1.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.75","Fee Schedule","","1.00","1.00",""
"TAMSULOSIN HCL 0.4 MG PO CAPS","","","68084-299-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.63","1.63","","","","1.63","Fee Schedule","","","","","1.63","Fee Schedule","","","","","1.63","Fee Schedule","","","52","","1.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.40","86","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","70","","","Percent of Total Billed Charges","neg_dollar:$1.14","","52","","1.63","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.96;102% of Medicaid interim rate","1.22","75","","","Percent of Total Billed Charges","neg_dollar:$1.22","1.40","86","","","Percent of Total Billed Charges","neg_dollar:$1.40","1.14","70","","","Percent of Total Billed Charges","neg_dollar:$1.14","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;103.5% of Medicaid interim rate","1.63","150","","","Percent of Total Billed Charges","neg_dollar:$2.53;150% of Medicaid interim rate","1.31","80","","","Percent of Total Billed Charges","neg_dollar:$1.31;Percent of Total Billed Charges","1.50","92","","","Percent of Total Billed Charges","neg_dollar:$1.50","0.85","52","","","Percent of Total Billed Charges","neg_dollar:$0.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.63","Fee Schedule","","1.00","1.00",""
"TAMSULOSIN HCL 0.4 MG PO CAPS","","","68084-299-11","NDC","637","RC","","Facility","Outpatient","1","ME","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","101% of Medicare Fee Schedule","","","","1.75","Fee Schedule","","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"TAMSULOSIN HCL 0.4 MG PO CAPS","","","68084-299-11","NDC","250","RC","","Facility","Outpatient","1","ME","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","","52","","1.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.75","Fee Schedule","","1.00","1.00",""
"LAMOTRIGINE 100 MG PO TABS","","","68084-319-11","NDC","250","RC","","Facility","Outpatient","100","ME","0.67","0.67","","","","0.67","Fee Schedule","","","","","0.67","Fee Schedule","","","","","0.67","Fee Schedule","","","52","","0.67","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.58","86","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.47","70","","","Percent of Total Billed Charges","neg_dollar:$0.47","","52","","0.67","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.39;102% of Medicaid interim rate","0.50","75","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.58","86","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.47","70","","","Percent of Total Billed Charges","neg_dollar:$0.47","0.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.38;103.5% of Medicaid interim rate","0.67","150","","","Percent of Total Billed Charges","neg_dollar:$1.04;150% of Medicaid interim rate","0.54","80","","","Percent of Total Billed Charges","neg_dollar:$0.54;Percent of Total Billed Charges","0.62","92","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.35","52","","","Percent of Total Billed Charges","neg_dollar:$0.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.67","Fee Schedule","","1.00","1.00",""
"TOPIRAMATE 50 MG PO TABS","","","68084-343-11","NDC","250","RC","","Facility","Outpatient","50","ME","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","","52","","1.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.31;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.50","Fee Schedule","","1.00","1.00",""
"LOSARTAN POTASSIUM 50 MG PO TABS","","","68084-347-11","NDC","637","RC","","Facility","Outpatient","50","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"LOSARTAN POTASSIUM 50 MG PO TABS","","","68084-347-11","NDC","250","RC","","Facility","Outpatient","50","ME","1.45","1.45","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","","","1.45","Fee Schedule","","","52","","1.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","","52","","1.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;102% of Medicaid interim rate","1.08","75","","","Percent of Total Billed Charges","neg_dollar:$1.08","1.24","86","","","Percent of Total Billed Charges","neg_dollar:$1.24","1.01","70","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.82;103.5% of Medicaid interim rate","1.45","150","","","Percent of Total Billed Charges","neg_dollar:$2.24;150% of Medicaid interim rate","1.16","80","","","Percent of Total Billed Charges","neg_dollar:$1.16;Percent of Total Billed Charges","1.33","92","","","Percent of Total Billed Charges","neg_dollar:$1.33","0.75","52","","","Percent of Total Billed Charges","neg_dollar:$0.75;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.45","Fee Schedule","","1.00","1.00",""
"OXYCODONE HCL 5 MG PO TABS","","","68084-354-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.55","1.55","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","","","1.55","Fee Schedule","","","52","","1.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","","52","","1.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% of Medicaid interim rate","1.16","75","","","Percent of Total Billed Charges","neg_dollar:$1.16","1.33","86","","","Percent of Total Billed Charges","neg_dollar:$1.33","1.08","70","","","Percent of Total Billed Charges","neg_dollar:$1.08","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;103.5% of Medicaid interim rate","1.55","150","","","Percent of Total Billed Charges","neg_dollar:$2.39;150% of Medicaid interim rate","1.24","80","","","Percent of Total Billed Charges","neg_dollar:$1.24;Percent of Total Billed Charges","1.42","92","","","Percent of Total Billed Charges","neg_dollar:$1.42","0.80","52","","","Percent of Total Billed Charges","neg_dollar:$0.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.55","Fee Schedule","","1.00","1.00",""
"OXYCODONE HCL 5 MG PO TABS","","","68084-354-11","NDC","250","RC","","Facility","Outpatient","5","ME","1.47","1.47","","","","1.47","Fee Schedule","","","","","1.47","Fee Schedule","","","","","1.47","Fee Schedule","","","52","","1.47","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.26","86","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","","52","","1.47","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.86;102% of Medicaid interim rate","1.10","75","","","Percent of Total Billed Charges","neg_dollar:$1.10","1.26","86","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.03","70","","","Percent of Total Billed Charges","neg_dollar:$1.03","0.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.84;103.5% of Medicaid interim rate","1.47","150","","","Percent of Total Billed Charges","neg_dollar:$2.27;150% of Medicaid interim rate","1.17","80","","","Percent of Total Billed Charges","neg_dollar:$1.17;Percent of Total Billed Charges","1.35","92","","","Percent of Total Billed Charges","neg_dollar:$1.35","0.76","52","","","Percent of Total Billed Charges","neg_dollar:$0.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.47","Fee Schedule","","1.00","1.00",""
"OXYCODONE HCL 5 MG PO TABS","","","68084-354-11","NDC","637","RC","","Facility","Outpatient","5","ME","1.60","1.60","","","","1.60","Fee Schedule","","","","","1.60","Fee Schedule","101% of Medicare Fee Schedule","","","","1.60","Fee Schedule","","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% of Medicaid interim rate","1.20","75","","","Percent of Total Billed Charges","neg_dollar:$1.20","1.37","86","","","Percent of Total Billed Charges","neg_dollar:$1.37","1.11","70","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.91;103.5% of Medicaid interim rate","1.60","150","","","Percent of Total Billed Charges","neg_dollar:$2.47;150% of Medicaid interim rate","1.28","80","","","Percent of Total Billed Charges","neg_dollar:$1.28;Percent of Total Billed Charges","1.47","92","","","Percent of Total Billed Charges","neg_dollar:$1.47","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.83","52","","","Percent of Total Billed Charges","neg_dollar:$0.83;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"OXYCODONE HCL 5 MG PO TABS","","","68084-354-11","NDC","637","RC","","Facility","Outpatient","5","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","101% of Medicare Fee Schedule","","","","1.25","Fee Schedule","","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"DIVALPROEX SODIUM ER 500 MG PO TB24","","","68084-415-11","NDC","250","RC","","Facility","Outpatient","500","ME","3.40","3.40","","","","3.40","Fee Schedule","","","","","3.40","Fee Schedule","","","","","3.40","Fee Schedule","","","52","","3.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.92","86","","","Percent of Total Billed Charges","neg_dollar:$2.92","2.38","70","","","Percent of Total Billed Charges","neg_dollar:$2.38","","52","","3.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.99;102% of Medicaid interim rate","2.55","75","","","Percent of Total Billed Charges","neg_dollar:$2.55","2.92","86","","","Percent of Total Billed Charges","neg_dollar:$2.92","2.38","70","","","Percent of Total Billed Charges","neg_dollar:$2.38","1.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.93;103.5% of Medicaid interim rate","3.40","150","","","Percent of Total Billed Charges","neg_dollar:$5.25;150% of Medicaid interim rate","2.72","80","","","Percent of Total Billed Charges","neg_dollar:$2.72;Percent of Total Billed Charges","3.12","92","","","Percent of Total Billed Charges","neg_dollar:$3.12","1.76","52","","","Percent of Total Billed Charges","neg_dollar:$1.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.40","Fee Schedule","","1.00","3.00",""
"HYDRALAZINE HCL 10 MG PO TABS","","","68084-447-11","NDC","250","RC","","Facility","Outpatient","10","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"CLOPIDOGREL BISULFATE 75 MG PO TABS","","","68084-536-11","NDC","637","RC","","Facility","Outpatient","75","ME","0.82","0.82","","","","0.82","Fee Schedule","","","","","0.82","Fee Schedule","101% of Medicare Fee Schedule","","","","0.82","Fee Schedule","","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","0.82","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.70","86","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;105% Medicare Outpatient Cost to Charge Ratio of 52%","0.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.48;102% of Medicaid interim rate","0.61","75","","","Percent of Total Billed Charges","neg_dollar:$0.61","0.70","86","","","Percent of Total Billed Charges","neg_dollar:$0.70","0.57","70","","","Percent of Total Billed Charges","neg_dollar:$0.57","0.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.47;103.5% of Medicaid interim rate","0.82","150","","","Percent of Total Billed Charges","neg_dollar:$1.27;150% of Medicaid interim rate","0.66","80","","","Percent of Total Billed Charges","neg_dollar:$0.66;Percent of Total Billed Charges","0.75","92","","","Percent of Total Billed Charges","neg_dollar:$0.75","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","52","","","Percent of Total Billed Charges","neg_dollar:$0.42;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"CLOPIDOGREL BISULFATE 75 MG PO TABS","","","68084-536-11","NDC","250","RC","","Facility","Outpatient","75","ME","0.90","0.90","","","","0.90","Fee Schedule","","","","","0.90","Fee Schedule","","","","","0.90","Fee Schedule","","","52","","0.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","","52","","0.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.52;102% of Medicaid interim rate","0.67","75","","","Percent of Total Billed Charges","neg_dollar:$0.67","0.77","86","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.63","70","","","Percent of Total Billed Charges","neg_dollar:$0.63","0.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.51;103.5% of Medicaid interim rate","0.90","150","","","Percent of Total Billed Charges","neg_dollar:$1.39;150% of Medicaid interim rate","0.72","80","","","Percent of Total Billed Charges","neg_dollar:$0.72;Percent of Total Billed Charges","0.82","92","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.46","52","","","Percent of Total Billed Charges","neg_dollar:$0.46;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.90","Fee Schedule","","1.00","1.00",""
"GUAIFENESIN ER 600 MG PO TB12","","","68084-572-11","NDC","250","RC","","Facility","Outpatient","600","ME","2.05","2.05","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","","","2.05","Fee Schedule","","","52","","2.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","","52","","2.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.20;102% of Medicaid interim rate","1.53","75","","","Percent of Total Billed Charges","neg_dollar:$1.53","1.76","86","","","Percent of Total Billed Charges","neg_dollar:$1.76","1.43","70","","","Percent of Total Billed Charges","neg_dollar:$1.43","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;103.5% of Medicaid interim rate","2.05","150","","","Percent of Total Billed Charges","neg_dollar:$3.16;150% of Medicaid interim rate","1.64","80","","","Percent of Total Billed Charges","neg_dollar:$1.64;Percent of Total Billed Charges","1.88","92","","","Percent of Total Billed Charges","neg_dollar:$1.88","1.06","52","","","Percent of Total Billed Charges","neg_dollar:$1.06;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.05","Fee Schedule","","1.00","2.00",""
"ESCITALOPRAM OXALATE 10 MG PO TABS","","","68084-617-11","NDC","250","RC","","Facility","Outpatient","10","ME","0.72","0.72","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","","","0.72","Fee Schedule","","","52","","0.72","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","","52","","0.72","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.42;102% of Medicaid interim rate","0.54","75","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.62","86","","","Percent of Total Billed Charges","neg_dollar:$0.62","0.50","70","","","Percent of Total Billed Charges","neg_dollar:$0.50","0.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.41;103.5% of Medicaid interim rate","0.72","150","","","Percent of Total Billed Charges","neg_dollar:$1.11;150% of Medicaid interim rate","0.57","80","","","Percent of Total Billed Charges","neg_dollar:$0.57;Percent of Total Billed Charges","0.66","92","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.37","52","","","Percent of Total Billed Charges","neg_dollar:$0.37;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.72","Fee Schedule","","1.00","1.00",""
"TIZANIDINE HCL 4 MG PO TABS","","","68084-645-01","NDC","250","RC","","Facility","Outpatient","4","ME","1.80","1.80","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","","52","","1.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;102% of Medicaid interim rate","1.35","75","","","Percent of Total Billed Charges","neg_dollar:$1.35","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;103.5% of Medicaid interim rate","1.80","150","","","Percent of Total Billed Charges","neg_dollar:$2.78;150% of Medicaid interim rate","1.44","80","","","Percent of Total Billed Charges","neg_dollar:$1.44;Percent of Total Billed Charges","1.65","92","","","Percent of Total Billed Charges","neg_dollar:$1.65","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.80","Fee Schedule","","1.00","1.00",""
"TIZANIDINE HCL 4 MG PO TABS","","","68084-645-11","NDC","250","RC","","Facility","Outpatient","4","ME","1.80","1.80","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","","","","","1.80","Fee Schedule","","","52","","1.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","","52","","1.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.05;102% of Medicaid interim rate","1.35","75","","","Percent of Total Billed Charges","neg_dollar:$1.35","1.54","86","","","Percent of Total Billed Charges","neg_dollar:$1.54","1.26","70","","","Percent of Total Billed Charges","neg_dollar:$1.26","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;103.5% of Medicaid interim rate","1.80","150","","","Percent of Total Billed Charges","neg_dollar:$2.78;150% of Medicaid interim rate","1.44","80","","","Percent of Total Billed Charges","neg_dollar:$1.44;Percent of Total Billed Charges","1.65","92","","","Percent of Total Billed Charges","neg_dollar:$1.65","0.93","52","","","Percent of Total Billed Charges","neg_dollar:$0.93;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.80","Fee Schedule","","1.00","1.00",""
"BUPROPION HCL ER (SR) 150 MG PO TB12","","","68084-708-95","NDC","250","RC","","Facility","Outpatient","1","EA","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","","52","","1.75","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.75","Fee Schedule","","1.00","1.00",""
"VENLAFAXINE HCL ER 75 MG PO CP24","","","68084-709-11","NDC","250","RC","","Facility","Outpatient","75","ME","1.15","1.15","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","","","1.15","Fee Schedule","","","52","","1.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","","52","","1.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% of Medicaid interim rate","0.86","75","","","Percent of Total Billed Charges","neg_dollar:$0.86","0.98","86","","","Percent of Total Billed Charges","neg_dollar:$0.98","0.80","70","","","Percent of Total Billed Charges","neg_dollar:$0.80","0.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.65;103.5% of Medicaid interim rate","1.15","150","","","Percent of Total Billed Charges","neg_dollar:$1.77;150% of Medicaid interim rate","0.91","80","","","Percent of Total Billed Charges","neg_dollar:$0.91;Percent of Total Billed Charges","1.05","92","","","Percent of Total Billed Charges","neg_dollar:$1.05","0.59","52","","","Percent of Total Billed Charges","neg_dollar:$0.59;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.15","Fee Schedule","","1.00","1.00",""
"DIVALPROEX SODIUM 250 MG PO TBEC","","","68084-776-11","NDC","250","RC","","Facility","Outpatient","1","UN","0.53","0.53","","","","0.53","Fee Schedule","","","","","0.53","Fee Schedule","","","","","0.53","Fee Schedule","","","52","","0.53","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.46","86","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.37","70","","","Percent of Total Billed Charges","neg_dollar:$0.37","","52","","0.53","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.31;102% of Medicaid interim rate","0.40","75","","","Percent of Total Billed Charges","neg_dollar:$0.40","0.46","86","","","Percent of Total Billed Charges","neg_dollar:$0.46","0.37","70","","","Percent of Total Billed Charges","neg_dollar:$0.37","0.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.30;103.5% of Medicaid interim rate","0.53","150","","","Percent of Total Billed Charges","neg_dollar:$0.83;150% of Medicaid interim rate","0.43","80","","","Percent of Total Billed Charges","neg_dollar:$0.43;Percent of Total Billed Charges","0.49","92","","","Percent of Total Billed Charges","neg_dollar:$0.49","0.27","52","","","Percent of Total Billed Charges","neg_dollar:$0.27;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.53","Fee Schedule","","1.00","1.00",""
"TRAMADOL HCL 50 MG PO TABS","","","68084-808-11","NDC","250","RC","","Facility","Outpatient","50","ME","1.27","1.27","","","","1.27","Fee Schedule","","","","","1.27","Fee Schedule","","","","","1.27","Fee Schedule","","","52","","1.27","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.09","86","","","Percent of Total Billed Charges","neg_dollar:$1.09","0.89","70","","","Percent of Total Billed Charges","neg_dollar:$0.89","","52","","1.27","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.75;102% of Medicaid interim rate","0.95","75","","","Percent of Total Billed Charges","neg_dollar:$0.95","1.09","86","","","Percent of Total Billed Charges","neg_dollar:$1.09","0.89","70","","","Percent of Total Billed Charges","neg_dollar:$0.89","0.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.72;103.5% of Medicaid interim rate","1.27","150","","","Percent of Total Billed Charges","neg_dollar:$1.97;150% of Medicaid interim rate","1.02","80","","","Percent of Total Billed Charges","neg_dollar:$1.02;Percent of Total Billed Charges","1.17","92","","","Percent of Total Billed Charges","neg_dollar:$1.17","0.66","52","","","Percent of Total Billed Charges","neg_dollar:$0.66;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.27","Fee Schedule","","1.00","1.00",""
"MELATONIN 3 MG PO TABS","","","68094-110-59","NDC","250","RC","","Facility","Outpatient","3","ME","0.77","0.77","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","","","","","0.77","Fee Schedule","","","52","","0.77","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","","52","","0.77","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.45;102% of Medicaid interim rate","0.58","75","","","Percent of Total Billed Charges","neg_dollar:$0.58","0.66","86","","","Percent of Total Billed Charges","neg_dollar:$0.66","0.54","70","","","Percent of Total Billed Charges","neg_dollar:$0.54","0.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.44;103.5% of Medicaid interim rate","0.77","150","","","Percent of Total Billed Charges","neg_dollar:$1.19;150% of Medicaid interim rate","0.62","80","","","Percent of Total Billed Charges","neg_dollar:$0.62;Percent of Total Billed Charges","0.71","92","","","Percent of Total Billed Charges","neg_dollar:$0.71","0.40","52","","","Percent of Total Billed Charges","neg_dollar:$0.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.77","Fee Schedule","","1.00","1.00",""
"ACETAMINOPHEN 160 MG/5ML PO SUSP PEDIATRIC","","","68094-231-59","NDC","250","RC","","Facility","Outpatient","1","EA","0.22","0.22","","","","0.22","Fee Schedule","","","","","0.22","Fee Schedule","","","","","0.22","Fee Schedule","","","52","","0.22","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.11","52","","","Percent of Total Billed Charges","neg_dollar:$0.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.11","52","","","Percent of Total Billed Charges","neg_dollar:$0.11;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.19","86","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.15","70","","","Percent of Total Billed Charges","neg_dollar:$0.15","","52","","0.22","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.13;102% of Medicaid interim rate","0.16","75","","","Percent of Total Billed Charges","neg_dollar:$0.16","0.19","86","","","Percent of Total Billed Charges","neg_dollar:$0.19","0.15","70","","","Percent of Total Billed Charges","neg_dollar:$0.15","0.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.12;103.5% of Medicaid interim rate","0.22","150","","","Percent of Total Billed Charges","neg_dollar:$0.34;150% of Medicaid interim rate","0.18","80","","","Percent of Total Billed Charges","neg_dollar:$0.18;Percent of Total Billed Charges","0.20","92","","","Percent of Total Billed Charges","neg_dollar:$0.20","0.11","52","","","Percent of Total Billed Charges","neg_dollar:$0.11;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","0.22","Fee Schedule","","1.00","1.00",""
"IBUPROFEN 100 MG/5ML PO SUSP","","","68094-600-59","NDC","250","RC","","Facility","Outpatient","1","EA","1.18","1.18","","","","1.18","Fee Schedule","","","","","1.18","Fee Schedule","","","","","1.18","Fee Schedule","","","52","","1.18","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","86","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.83","70","","","Percent of Total Billed Charges","neg_dollar:$0.83","","52","","1.18","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.69;102% of Medicaid interim rate","0.89","75","","","Percent of Total Billed Charges","neg_dollar:$0.89","1.02","86","","","Percent of Total Billed Charges","neg_dollar:$1.02","0.83","70","","","Percent of Total Billed Charges","neg_dollar:$0.83","0.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.67;103.5% of Medicaid interim rate","1.18","150","","","Percent of Total Billed Charges","neg_dollar:$1.83;150% of Medicaid interim rate","0.95","80","","","Percent of Total Billed Charges","neg_dollar:$0.95;Percent of Total Billed Charges","1.09","92","","","Percent of Total Billed Charges","neg_dollar:$1.09","0.61","52","","","Percent of Total Billed Charges","neg_dollar:$0.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.18","Fee Schedule","","1.00","1.00",""
"IBUPROFEN 100 MG/5ML PO SUSP","","","68094-600-59","NDC","637","RC","","Facility","Outpatient","1","EA","1.75","1.75","","","","1.75","Fee Schedule","","","","","1.75","Fee Schedule","101% of Medicare Fee Schedule","","","","1.75","Fee Schedule","","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","1.75","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;105% Medicare Outpatient Cost to Charge Ratio of 52%","1.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.02;102% of Medicaid interim rate","1.31","75","","","Percent of Total Billed Charges","neg_dollar:$1.31","1.50","86","","","Percent of Total Billed Charges","neg_dollar:$1.50","1.22","70","","","Percent of Total Billed Charges","neg_dollar:$1.22","0.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.99;103.5% of Medicaid interim rate","1.75","150","","","Percent of Total Billed Charges","neg_dollar:$2.70;150% of Medicaid interim rate","1.40","80","","","Percent of Total Billed Charges","neg_dollar:$1.40;Percent of Total Billed Charges","1.61","92","","","Percent of Total Billed Charges","neg_dollar:$1.61","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","0.91","52","","","Percent of Total Billed Charges","neg_dollar:$0.91;100% Medicare Outpatient Cost to Charge Ratio of 52%","1.00","1.00",""
"MOXIFLOXACIN HCL 0.5 % OP SOLN","","","68180-422-01","NDC","250","RC","","Facility","Outpatient","1","EA","27","27.00","","","","27.00","Fee Schedule","","","","","27.00","Fee Schedule","","","","","27.00","Fee Schedule","","","52","","27.00","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","14.04","52","","","Percent of Total Billed Charges","neg_dollar:$14.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","14.04","52","","","Percent of Total Billed Charges","neg_dollar:$14.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","23.22","86","","","Percent of Total Billed Charges","neg_dollar:$23.22","18.90","70","","","Percent of Total Billed Charges","neg_dollar:$18.90","","52","","27.00","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","15.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.86;102% of Medicaid interim rate","20.25","75","","","Percent of Total Billed Charges","neg_dollar:$20.25","23.22","86","","","Percent of Total Billed Charges","neg_dollar:$23.22","18.90","70","","","Percent of Total Billed Charges","neg_dollar:$18.90","15.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$15.38;103.5% of Medicaid interim rate","27.00","150","","","Percent of Total Billed Charges","neg_dollar:$41.74;150% of Medicaid interim rate","21.60","80","","","Percent of Total Billed Charges","neg_dollar:$21.60;Percent of Total Billed Charges","24.84","92","","","Percent of Total Billed Charges","neg_dollar:$24.84","14.04","52","","","Percent of Total Billed Charges","neg_dollar:$14.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","27.00","Fee Schedule","","14.00","27.00",""
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS","","","68180-677-11","NDC","250","RC","","Facility","Outpatient","75","ME","4.15","4.15","","","","4.15","Fee Schedule","","","","","4.15","Fee Schedule","","","","","4.15","Fee Schedule","","","52","","4.15","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.15","52","","","Percent of Total Billed Charges","neg_dollar:$2.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.15","52","","","Percent of Total Billed Charges","neg_dollar:$2.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.56","86","","","Percent of Total Billed Charges","neg_dollar:$3.56","2.90","70","","","Percent of Total Billed Charges","neg_dollar:$2.90","","52","","4.15","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.43;102% of Medicaid interim rate","3.11","75","","","Percent of Total Billed Charges","neg_dollar:$3.11","3.56","86","","","Percent of Total Billed Charges","neg_dollar:$3.56","2.90","70","","","Percent of Total Billed Charges","neg_dollar:$2.90","2.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.36;103.5% of Medicaid interim rate","4.15","150","","","Percent of Total Billed Charges","neg_dollar:$6.41;150% of Medicaid interim rate","3.32","80","","","Percent of Total Billed Charges","neg_dollar:$3.32;Percent of Total Billed Charges","3.81","92","","","Percent of Total Billed Charges","neg_dollar:$3.81","2.15","52","","","Percent of Total Billed Charges","neg_dollar:$2.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.15","Fee Schedule","","2.00","4.00",""
"MUPIROCIN 2 % EX OINT","","","68462-180-22","NDC","250","RC","","Facility","Outpatient","1","UN","20.40","20.40","","","","20.40","Fee Schedule","","","","","20.40","Fee Schedule","","","","","20.40","Fee Schedule","","","52","","20.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","17.54","86","","","Percent of Total Billed Charges","neg_dollar:$17.54","14.27","70","","","Percent of Total Billed Charges","neg_dollar:$14.27","","52","","20.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","11.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.98;102% of Medicaid interim rate","15.29","75","","","Percent of Total Billed Charges","neg_dollar:$15.29","17.54","86","","","Percent of Total Billed Charges","neg_dollar:$17.54","14.27","70","","","Percent of Total Billed Charges","neg_dollar:$14.27","11.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.62;103.5% of Medicaid interim rate","20.40","150","","","Percent of Total Billed Charges","neg_dollar:$31.53;150% of Medicaid interim rate","16.32","80","","","Percent of Total Billed Charges","neg_dollar:$16.32;Percent of Total Billed Charges","18.76","92","","","Percent of Total Billed Charges","neg_dollar:$18.76","10.60","52","","","Percent of Total Billed Charges","neg_dollar:$10.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","20.40","Fee Schedule","","10.00","20.00",""
"NITROGLYCERIN 0.4 MG SL SUBL","","","68462-639-25","NDC","637","RC","","Facility","Outpatient","1","ME","13.40","13.40","","","","13.40","Fee Schedule","","","","","13.40","Fee Schedule","101% of Medicare Fee Schedule","","","","13.40","Fee Schedule","","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","13.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.52","86","","","Percent of Total Billed Charges","neg_dollar:$11.52","9.37","70","","","Percent of Total Billed Charges","neg_dollar:$9.37","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.87;102% of Medicaid interim rate","10.05","75","","","Percent of Total Billed Charges","neg_dollar:$10.05","11.52","86","","","Percent of Total Billed Charges","neg_dollar:$11.52","9.37","70","","","Percent of Total Billed Charges","neg_dollar:$9.37","7.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.63;103.5% of Medicaid interim rate","13.40","150","","","Percent of Total Billed Charges","neg_dollar:$20.71;150% of Medicaid interim rate","10.72","80","","","Percent of Total Billed Charges","neg_dollar:$10.72;Percent of Total Billed Charges","12.32","92","","","Percent of Total Billed Charges","neg_dollar:$12.32","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","13.00",""
"NITROGLYCERIN 0.4 MG SL SUBL","","","68462-639-25","NDC","250","RC","","Facility","Outpatient","1","ME","13.40","13.40","","","","13.40","Fee Schedule","","","","","13.40","Fee Schedule","","","","","13.40","Fee Schedule","","","52","","13.40","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","11.52","86","","","Percent of Total Billed Charges","neg_dollar:$11.52","9.37","70","","","Percent of Total Billed Charges","neg_dollar:$9.37","","52","","13.40","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","7.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.87;102% of Medicaid interim rate","10.05","75","","","Percent of Total Billed Charges","neg_dollar:$10.05","11.52","86","","","Percent of Total Billed Charges","neg_dollar:$11.52","9.37","70","","","Percent of Total Billed Charges","neg_dollar:$9.37","7.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.63;103.5% of Medicaid interim rate","13.40","150","","","Percent of Total Billed Charges","neg_dollar:$20.71;150% of Medicaid interim rate","10.72","80","","","Percent of Total Billed Charges","neg_dollar:$10.72;Percent of Total Billed Charges","12.32","92","","","Percent of Total Billed Charges","neg_dollar:$12.32","6.96","52","","","Percent of Total Billed Charges","neg_dollar:$6.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","13.40","Fee Schedule","","6.00","13.00",""
"TRYPAN BLUE 0.06 % IO SOSY","","","68803-612-10","NDC","250","RC","","Facility","Outpatient","1","EA","192.60","192.60","","","","192.60","Fee Schedule","","","","","192.60","Fee Schedule","","","","","192.60","Fee Schedule","","","52","","192.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","100.15","52","","","Percent of Total Billed Charges","neg_dollar:$100.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","100.15","52","","","Percent of Total Billed Charges","neg_dollar:$100.15;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.63","86","","","Percent of Total Billed Charges","neg_dollar:$165.63","134.82","70","","","Percent of Total Billed Charges","neg_dollar:$134.82","","52","","192.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","113.15","56.99","","","Percent of Total Billed Charges","neg_dollar:$113.15;102% of Medicaid interim rate","144.45","75","","","Percent of Total Billed Charges","neg_dollar:$144.45","165.63","86","","","Percent of Total Billed Charges","neg_dollar:$165.63","134.82","70","","","Percent of Total Billed Charges","neg_dollar:$134.82","109.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$109.78;103.5% of Medicaid interim rate","192.60","150","","","Percent of Total Billed Charges","neg_dollar:$297.76;150% of Medicaid interim rate","154.08","80","","","Percent of Total Billed Charges","neg_dollar:$154.08;Percent of Total Billed Charges","177.19","92","","","Percent of Total Billed Charges","neg_dollar:$177.19","100.15","52","","","Percent of Total Billed Charges","neg_dollar:$100.15;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","192.60","Fee Schedule","","100.00","192.00",""
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS","","","69097-142-60","NDC","250","RC","","Facility","Outpatient","1","UN","39.10","39.10","","","","39.10","Fee Schedule","","","","","39.10","Fee Schedule","","","","","39.10","Fee Schedule","","","52","","39.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","20.33","52","","","Percent of Total Billed Charges","neg_dollar:$20.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","20.33","52","","","Percent of Total Billed Charges","neg_dollar:$20.33;102% Medicare Outpatient Cost to Charge Ratio of 52%","33.62","86","","","Percent of Total Billed Charges","neg_dollar:$33.62","27.37","70","","","Percent of Total Billed Charges","neg_dollar:$27.37","","52","","39.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","22.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.97;102% of Medicaid interim rate","29.32","75","","","Percent of Total Billed Charges","neg_dollar:$29.32","33.62","86","","","Percent of Total Billed Charges","neg_dollar:$33.62","27.37","70","","","Percent of Total Billed Charges","neg_dollar:$27.37","22.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.28;103.5% of Medicaid interim rate","39.10","150","","","Percent of Total Billed Charges","neg_dollar:$60.45;150% of Medicaid interim rate","31.28","80","","","Percent of Total Billed Charges","neg_dollar:$31.28;Percent of Total Billed Charges","35.97","92","","","Percent of Total Billed Charges","neg_dollar:$35.97","20.33","52","","","Percent of Total Billed Charges","neg_dollar:$20.33;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","39.10","Fee Schedule","","20.00","39.00",""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS","","","69238-1264-1","NDC","250","RC","","Facility","Outpatient","30","ME","10.55","10.55","","","","10.55","Fee Schedule","","","","","10.55","Fee Schedule","","","","","10.55","Fee Schedule","","","52","","10.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.48","52","","","Percent of Total Billed Charges","neg_dollar:$5.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.48","52","","","Percent of Total Billed Charges","neg_dollar:$5.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.07","86","","","Percent of Total Billed Charges","neg_dollar:$9.07","7.38","70","","","Percent of Total Billed Charges","neg_dollar:$7.38","","52","","10.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","6.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.19;102% of Medicaid interim rate","7.91","75","","","Percent of Total Billed Charges","neg_dollar:$7.91","9.07","86","","","Percent of Total Billed Charges","neg_dollar:$9.07","7.38","70","","","Percent of Total Billed Charges","neg_dollar:$7.38","6.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$6.01;103.5% of Medicaid interim rate","10.55","150","","","Percent of Total Billed Charges","neg_dollar:$16.31;150% of Medicaid interim rate","8.44","80","","","Percent of Total Billed Charges","neg_dollar:$8.44;Percent of Total Billed Charges","9.70","92","","","Percent of Total Billed Charges","neg_dollar:$9.70","5.48","52","","","Percent of Total Billed Charges","neg_dollar:$5.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","10.55","Fee Schedule","","5.00","10.00",""
"LORAZEPAM 0.5 MG PO TABS","","","69315-904-01","NDC","250","RC","","Facility","Outpatient","1","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD","","","69339-151-17","NDC","637","RC","","Facility","Outpatient","1","UN","12.85","12.85","","","","12.85","Fee Schedule","","","","","12.85","Fee Schedule","101% of Medicare Fee Schedule","","","","12.85","Fee Schedule","","6.68","52","","","Percent of Total Billed Charges","neg_dollar:$6.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","12.85","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","11.05","86","","","Percent of Total Billed Charges","neg_dollar:$11.05","8.99","70","","","Percent of Total Billed Charges","neg_dollar:$8.99","6.68","52","","","Percent of Total Billed Charges","neg_dollar:$6.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","7.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.54;102% of Medicaid interim rate","9.63","75","","","Percent of Total Billed Charges","neg_dollar:$9.63","11.05","86","","","Percent of Total Billed Charges","neg_dollar:$11.05","8.99","70","","","Percent of Total Billed Charges","neg_dollar:$8.99","7.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$7.32;103.5% of Medicaid interim rate","12.85","150","","","Percent of Total Billed Charges","neg_dollar:$19.86;150% of Medicaid interim rate","10.28","80","","","Percent of Total Billed Charges","neg_dollar:$10.28;Percent of Total Billed Charges","11.82","92","","","Percent of Total Billed Charges","neg_dollar:$11.82","6.68","52","","","Percent of Total Billed Charges","neg_dollar:$6.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.68","52","","","Percent of Total Billed Charges","neg_dollar:$6.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","6.00","12.00",""
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD","","","69339-151-19","NDC","250","RC","","Facility","Outpatient","1","UN","9.88","9.88","","","","9.88","Fee Schedule","","","","","9.88","Fee Schedule","","","","","9.88","Fee Schedule","","","52","","9.88","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","5.14","52","","","Percent of Total Billed Charges","neg_dollar:$5.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","5.14","52","","","Percent of Total Billed Charges","neg_dollar:$5.14;102% Medicare Outpatient Cost to Charge Ratio of 52%","8.50","86","","","Percent of Total Billed Charges","neg_dollar:$8.50","6.92","70","","","Percent of Total Billed Charges","neg_dollar:$6.92","","52","","9.88","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","5.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.80;102% of Medicaid interim rate","7.41","75","","","Percent of Total Billed Charges","neg_dollar:$7.41","8.50","86","","","Percent of Total Billed Charges","neg_dollar:$8.50","6.92","70","","","Percent of Total Billed Charges","neg_dollar:$6.92","5.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$5.63;103.5% of Medicaid interim rate","9.88","150","","","Percent of Total Billed Charges","neg_dollar:$15.28;150% of Medicaid interim rate","7.91","80","","","Percent of Total Billed Charges","neg_dollar:$7.91;Percent of Total Billed Charges","9.09","92","","","Percent of Total Billed Charges","neg_dollar:$9.09","5.14","52","","","Percent of Total Billed Charges","neg_dollar:$5.14;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","9.88","Fee Schedule","","5.00","9.00",""
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP","","","69339-153-01","NDC","250","RC","","Facility","Outpatient","1","UN","3.70","3.70","","","","3.70","Fee Schedule","","","","","3.70","Fee Schedule","","","","","3.70","Fee Schedule","","","52","","3.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.92","52","","","Percent of Total Billed Charges","neg_dollar:$1.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.92","52","","","Percent of Total Billed Charges","neg_dollar:$1.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.18","86","","","Percent of Total Billed Charges","neg_dollar:$3.18","2.59","70","","","Percent of Total Billed Charges","neg_dollar:$2.59","","52","","3.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.17;102% of Medicaid interim rate","2.77","75","","","Percent of Total Billed Charges","neg_dollar:$2.77","3.18","86","","","Percent of Total Billed Charges","neg_dollar:$3.18","2.59","70","","","Percent of Total Billed Charges","neg_dollar:$2.59","2.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.10;103.5% of Medicaid interim rate","3.70","150","","","Percent of Total Billed Charges","neg_dollar:$5.72;150% of Medicaid interim rate","2.96","80","","","Percent of Total Billed Charges","neg_dollar:$2.96;Percent of Total Billed Charges","3.40","92","","","Percent of Total Billed Charges","neg_dollar:$3.40","1.92","52","","","Percent of Total Billed Charges","neg_dollar:$1.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.70","Fee Schedule","","1.00","3.00",""
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP","","","69339-153-17","NDC","250","RC","","Facility","Outpatient","1","UN","3.70","3.70","","","","3.70","Fee Schedule","","","","","3.70","Fee Schedule","","","","","3.70","Fee Schedule","","","52","","3.70","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.92","52","","","Percent of Total Billed Charges","neg_dollar:$1.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.92","52","","","Percent of Total Billed Charges","neg_dollar:$1.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.18","86","","","Percent of Total Billed Charges","neg_dollar:$3.18","2.59","70","","","Percent of Total Billed Charges","neg_dollar:$2.59","","52","","3.70","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.17;102% of Medicaid interim rate","2.77","75","","","Percent of Total Billed Charges","neg_dollar:$2.77","3.18","86","","","Percent of Total Billed Charges","neg_dollar:$3.18","2.59","70","","","Percent of Total Billed Charges","neg_dollar:$2.59","2.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.10;103.5% of Medicaid interim rate","3.70","150","","","Percent of Total Billed Charges","neg_dollar:$5.72;150% of Medicaid interim rate","2.96","80","","","Percent of Total Billed Charges","neg_dollar:$2.96;Percent of Total Billed Charges","3.40","92","","","Percent of Total Billed Charges","neg_dollar:$3.40","1.92","52","","","Percent of Total Billed Charges","neg_dollar:$1.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.70","Fee Schedule","","1.00","3.00",""
"MAGNESIUM CITRATE 1.745 GM/30ML PO SOLN","","","69452-389-98","NDC","250","RC","","Facility","Outpatient","1","UN","1.98","1.98","","","","1.98","Fee Schedule","","","","","1.98","Fee Schedule","","","","","1.98","Fee Schedule","","","52","","1.98","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","52","","","Percent of Total Billed Charges","neg_dollar:$1.03;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.03","52","","","Percent of Total Billed Charges","neg_dollar:$1.03;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.70","86","","","Percent of Total Billed Charges","neg_dollar:$1.70","1.38","70","","","Percent of Total Billed Charges","neg_dollar:$1.38","","52","","1.98","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.16;102% of Medicaid interim rate","1.48","75","","","Percent of Total Billed Charges","neg_dollar:$1.48","1.70","86","","","Percent of Total Billed Charges","neg_dollar:$1.70","1.38","70","","","Percent of Total Billed Charges","neg_dollar:$1.38","1.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.13;103.5% of Medicaid interim rate","1.98","150","","","Percent of Total Billed Charges","neg_dollar:$3.06;150% of Medicaid interim rate","1.58","80","","","Percent of Total Billed Charges","neg_dollar:$1.58;Percent of Total Billed Charges","1.82","92","","","Percent of Total Billed Charges","neg_dollar:$1.82","1.03","52","","","Percent of Total Billed Charges","neg_dollar:$1.03;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.98","Fee Schedule","","1.00","1.00",""
"INDOCYANINE GREEN 25 MG IV SOLR","","","70100-424-02","NDC","250","RC","","Facility","Outpatient","1","EA","106.90","106.90","","","","106.90","Fee Schedule","","","","","106.90","Fee Schedule","","","","","106.90","Fee Schedule","","","52","","106.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","55.58","52","","","Percent of Total Billed Charges","neg_dollar:$55.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","55.58","52","","","Percent of Total Billed Charges","neg_dollar:$55.58;102% Medicare Outpatient Cost to Charge Ratio of 52%","91.93","86","","","Percent of Total Billed Charges","neg_dollar:$91.93","74.83","70","","","Percent of Total Billed Charges","neg_dollar:$74.83","","52","","106.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","62.80","56.99","","","Percent of Total Billed Charges","neg_dollar:$62.80;102% of Medicaid interim rate","80.17","75","","","Percent of Total Billed Charges","neg_dollar:$80.17","91.93","86","","","Percent of Total Billed Charges","neg_dollar:$91.93","74.83","70","","","Percent of Total Billed Charges","neg_dollar:$74.83","60.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$60.93;103.5% of Medicaid interim rate","106.90","150","","","Percent of Total Billed Charges","neg_dollar:$165.27;150% of Medicaid interim rate","85.52","80","","","Percent of Total Billed Charges","neg_dollar:$85.52;Percent of Total Billed Charges","98.34","92","","","Percent of Total Billed Charges","neg_dollar:$98.34","55.58","52","","","Percent of Total Billed Charges","neg_dollar:$55.58;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","106.90","Fee Schedule","","55.00","106.00",""
"BACLOFEN 10 MG PO TABS","","","70710-1285-1","NDC","250","RC","","Facility","Outpatient","10","ME","1.10","1.10","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","","","1.10","Fee Schedule","","","52","","1.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","","52","","1.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.64;102% of Medicaid interim rate","0.82","75","","","Percent of Total Billed Charges","neg_dollar:$0.82","0.94","86","","","Percent of Total Billed Charges","neg_dollar:$0.94","0.77","70","","","Percent of Total Billed Charges","neg_dollar:$0.77","0.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.62;103.5% of Medicaid interim rate","1.10","150","","","Percent of Total Billed Charges","neg_dollar:$1.70;150% of Medicaid interim rate","0.88","80","","","Percent of Total Billed Charges","neg_dollar:$0.88;Percent of Total Billed Charges","1.01","92","","","Percent of Total Billed Charges","neg_dollar:$1.01","0.57","52","","","Percent of Total Billed Charges","neg_dollar:$0.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.10","Fee Schedule","","1.00","1.00",""
"LIDO-EPINEPHRINE-TETRACAINE 4-0.18-0.5 % EX GEL","","","71266-6290-1","NDC","250","RC","","Facility","Outpatient","1","EA","17.80","17.80","","","","17.80","Fee Schedule","","","","","17.80","Fee Schedule","","","","","17.80","Fee Schedule","","","52","","17.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","9.25","52","","","Percent of Total Billed Charges","neg_dollar:$9.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.25","52","","","Percent of Total Billed Charges","neg_dollar:$9.25;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.30","86","","","Percent of Total Billed Charges","neg_dollar:$15.30","12.45","70","","","Percent of Total Billed Charges","neg_dollar:$12.45","","52","","17.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","10.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.45;102% of Medicaid interim rate","13.35","75","","","Percent of Total Billed Charges","neg_dollar:$13.35","15.30","86","","","Percent of Total Billed Charges","neg_dollar:$15.30","12.45","70","","","Percent of Total Billed Charges","neg_dollar:$12.45","10.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.14;103.5% of Medicaid interim rate","17.80","150","","","Percent of Total Billed Charges","neg_dollar:$27.51;150% of Medicaid interim rate","14.24","80","","","Percent of Total Billed Charges","neg_dollar:$14.24;Percent of Total Billed Charges","16.37","92","","","Percent of Total Billed Charges","neg_dollar:$16.37","9.25","52","","","Percent of Total Billed Charges","neg_dollar:$9.25;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","17.80","Fee Schedule","","9.00","17.00",""
"DEXAMETHASONE-MOXIFLOXACIN 1-5 MG/ML IO SOLN","","","71384-512-01","NDC","250","RC","","Facility","Outpatient","1","UN","38.20","38.20","","","","38.20","Fee Schedule","","","","","38.20","Fee Schedule","","","","","38.20","Fee Schedule","","","52","","38.20","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","19.86","52","","","Percent of Total Billed Charges","neg_dollar:$19.86;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.86","52","","","Percent of Total Billed Charges","neg_dollar:$19.86;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.85","86","","","Percent of Total Billed Charges","neg_dollar:$32.85","26.74","70","","","Percent of Total Billed Charges","neg_dollar:$26.74","","52","","38.20","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","22.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.44;102% of Medicaid interim rate","28.65","75","","","Percent of Total Billed Charges","neg_dollar:$28.65","32.85","86","","","Percent of Total Billed Charges","neg_dollar:$32.85","26.74","70","","","Percent of Total Billed Charges","neg_dollar:$26.74","21.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.77;103.5% of Medicaid interim rate","38.20","150","","","Percent of Total Billed Charges","neg_dollar:$59.05;150% of Medicaid interim rate","30.56","80","","","Percent of Total Billed Charges","neg_dollar:$30.56;Percent of Total Billed Charges","35.14","92","","","Percent of Total Billed Charges","neg_dollar:$35.14","19.86","52","","","Percent of Total Billed Charges","neg_dollar:$19.86;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","38.20","Fee Schedule","","19.00","38.00",""
"TROPIC-PROPARACA-PE-KETOROLAC 1-0.5-2.5-0.5 % OP SOLN","","","71384-632-05","NDC","250","RC","","Facility","Outpatient","1","EA","83.10","83.10","","","","83.10","Fee Schedule","","","","","83.10","Fee Schedule","","","","","83.10","Fee Schedule","","","52","","83.10","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","43.21","52","","","Percent of Total Billed Charges","neg_dollar:$43.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","43.21","52","","","Percent of Total Billed Charges","neg_dollar:$43.21;102% Medicare Outpatient Cost to Charge Ratio of 52%","71.46","86","","","Percent of Total Billed Charges","neg_dollar:$71.46","58.16","70","","","Percent of Total Billed Charges","neg_dollar:$58.16","","52","","83.10","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","48.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$48.82;102% of Medicaid interim rate","62.32","75","","","Percent of Total Billed Charges","neg_dollar:$62.32","71.46","86","","","Percent of Total Billed Charges","neg_dollar:$71.46","58.16","70","","","Percent of Total Billed Charges","neg_dollar:$58.16","47.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$47.36;103.5% of Medicaid interim rate","83.10","150","","","Percent of Total Billed Charges","neg_dollar:$128.47;150% of Medicaid interim rate","66.48","80","","","Percent of Total Billed Charges","neg_dollar:$66.48;Percent of Total Billed Charges","76.45","92","","","Percent of Total Billed Charges","neg_dollar:$76.45","43.21","52","","","Percent of Total Billed Charges","neg_dollar:$43.21;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","83.10","Fee Schedule","","43.00","83.00",""
"MAGNESIUM CITRATE 1.745 GM/30ML PO SOLN","","","71399-0051-1","NDC","250","RC","","Facility","Outpatient","1","UN","4.60","4.60","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","","","","","4.60","Fee Schedule","","","52","","4.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","","52","","4.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.70;102% of Medicaid interim rate","3.44","75","","","Percent of Total Billed Charges","neg_dollar:$3.44","3.95","86","","","Percent of Total Billed Charges","neg_dollar:$3.95","3.21","70","","","Percent of Total Billed Charges","neg_dollar:$3.21","2.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.62;103.5% of Medicaid interim rate","4.60","150","","","Percent of Total Billed Charges","neg_dollar:$7.11;150% of Medicaid interim rate","3.67","80","","","Percent of Total Billed Charges","neg_dollar:$3.67;Percent of Total Billed Charges","4.23","92","","","Percent of Total Billed Charges","neg_dollar:$4.23","2.39","52","","","Percent of Total Billed Charges","neg_dollar:$2.39;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.60","Fee Schedule","","2.00","4.00",""
"SENNOSIDES 8.6 MG PO TABS","","","71399-8245-3","NDC","250","RC","","Facility","Outpatient","1","ME","1.05","1.05","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","","","1.05","Fee Schedule","","","52","","1.05","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","","52","","1.05","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.61;102% of Medicaid interim rate","0.78","75","","","Percent of Total Billed Charges","neg_dollar:$0.78","0.90","86","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.73","70","","","Percent of Total Billed Charges","neg_dollar:$0.73","0.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.59;103.5% of Medicaid interim rate","1.05","150","","","Percent of Total Billed Charges","neg_dollar:$1.62;150% of Medicaid interim rate","0.84","80","","","Percent of Total Billed Charges","neg_dollar:$0.84;Percent of Total Billed Charges","0.96","92","","","Percent of Total Billed Charges","neg_dollar:$0.96","0.54","52","","","Percent of Total Billed Charges","neg_dollar:$0.54;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.05","Fee Schedule","","1.00","1.00",""
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP","","","72485-625-13","NDC","250","RC","","Facility","Outpatient","1","UN","137.45","137.45","","","","137.45","Fee Schedule","","","","","137.45","Fee Schedule","","","","","137.45","Fee Schedule","","","52","","137.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","71.47","52","","","Percent of Total Billed Charges","neg_dollar:$71.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","71.47","52","","","Percent of Total Billed Charges","neg_dollar:$71.47;102% Medicare Outpatient Cost to Charge Ratio of 52%","118.20","86","","","Percent of Total Billed Charges","neg_dollar:$118.20","96.21","70","","","Percent of Total Billed Charges","neg_dollar:$96.21","","52","","137.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","80.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$80.75;102% of Medicaid interim rate","103.08","75","","","Percent of Total Billed Charges","neg_dollar:$103.08","118.20","86","","","Percent of Total Billed Charges","neg_dollar:$118.20","96.21","70","","","Percent of Total Billed Charges","neg_dollar:$96.21","78.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$78.34;103.5% of Medicaid interim rate","137.45","150","","","Percent of Total Billed Charges","neg_dollar:$212.50;150% of Medicaid interim rate","109.96","80","","","Percent of Total Billed Charges","neg_dollar:$109.96;Percent of Total Billed Charges","126.45","92","","","Percent of Total Billed Charges","neg_dollar:$126.45","71.47","52","","","Percent of Total Billed Charges","neg_dollar:$71.47;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","137.45","Fee Schedule","","71.00","137.00",""
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU","","","76204-200-01","NDC","250","RC","","Facility","Outpatient","1","EA","1.50","1.50","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","","","1.50","Fee Schedule","","","52","","1.50","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","","52","","1.50","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.88","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.88;102% of Medicaid interim rate","1.12","75","","","Percent of Total Billed Charges","neg_dollar:$1.12","1.29","86","","","Percent of Total Billed Charges","neg_dollar:$1.29","1.04","70","","","Percent of Total Billed Charges","neg_dollar:$1.04","0.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.85;103.5% of Medicaid interim rate","1.50","150","","","Percent of Total Billed Charges","neg_dollar:$2.31;150% of Medicaid interim rate","1.20","80","","","Percent of Total Billed Charges","neg_dollar:$1.20;Percent of Total Billed Charges","1.38","92","","","Percent of Total Billed Charges","neg_dollar:$1.38","0.78","52","","","Percent of Total Billed Charges","neg_dollar:$0.78;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.50","Fee Schedule","","1.00","1.00",""
"DEXTROSE 50 % IV SOLN","","","76329-3302-1","NDC","250","RC","","Facility","Outpatient","1","EA","122.26","122.26","","","","122.26","Fee Schedule","","","","","122.26","Fee Schedule","","","","","122.26","Fee Schedule","","","52","","122.26","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","63.57","52","","","Percent of Total Billed Charges","neg_dollar:$63.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","63.57","52","","","Percent of Total Billed Charges","neg_dollar:$63.57;102% Medicare Outpatient Cost to Charge Ratio of 52%","105.14","86","","","Percent of Total Billed Charges","neg_dollar:$105.14","85.58","70","","","Percent of Total Billed Charges","neg_dollar:$85.58","","52","","122.26","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","71.83","56.99","","","Percent of Total Billed Charges","neg_dollar:$71.83;102% of Medicaid interim rate","91.69","75","","","Percent of Total Billed Charges","neg_dollar:$91.69","105.14","86","","","Percent of Total Billed Charges","neg_dollar:$105.14","85.58","70","","","Percent of Total Billed Charges","neg_dollar:$85.58","69.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$69.69;103.5% of Medicaid interim rate","122.26","150","","","Percent of Total Billed Charges","neg_dollar:$189.03;150% of Medicaid interim rate","97.81","80","","","Percent of Total Billed Charges","neg_dollar:$97.81;Percent of Total Billed Charges","112.48","92","","","Percent of Total Billed Charges","neg_dollar:$112.48","63.57","52","","","Percent of Total Billed Charges","neg_dollar:$63.57;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","122.26","Fee Schedule","","63.00","122.00",""
"SODIUM BICARBONATE 8.4 % IV SOLN","","","76329-3352-1","NDC","250","RC","","Facility","Outpatient","1","EA","35.80","35.80","","","","35.80","Fee Schedule","","","","","35.80","Fee Schedule","","","","","35.80","Fee Schedule","","","52","","35.80","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","18.61","52","","","Percent of Total Billed Charges","neg_dollar:$18.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.61","52","","","Percent of Total Billed Charges","neg_dollar:$18.61;102% Medicare Outpatient Cost to Charge Ratio of 52%","30.78","86","","","Percent of Total Billed Charges","neg_dollar:$30.78","25.05","70","","","Percent of Total Billed Charges","neg_dollar:$25.05","","52","","35.80","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","21.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.03;102% of Medicaid interim rate","26.84","75","","","Percent of Total Billed Charges","neg_dollar:$26.84","30.78","86","","","Percent of Total Billed Charges","neg_dollar:$30.78","25.05","70","","","Percent of Total Billed Charges","neg_dollar:$25.05","20.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$20.40;103.5% of Medicaid interim rate","35.80","150","","","Percent of Total Billed Charges","neg_dollar:$55.34;150% of Medicaid interim rate","28.64","80","","","Percent of Total Billed Charges","neg_dollar:$28.64;Percent of Total Billed Charges","32.93","92","","","Percent of Total Billed Charges","neg_dollar:$32.93","18.61","52","","","Percent of Total Billed Charges","neg_dollar:$18.61;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","35.80","Fee Schedule","","18.00","35.00",""
"SIMETHICONE 80 MG PO CHEW","","","77333-812-25","NDC","250","RC","","Facility","Outpatient","80","ME","1.25","1.25","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","","","1.25","Fee Schedule","","","52","","1.25","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","","52","","1.25","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.73;102% of Medicaid interim rate","0.93","75","","","Percent of Total Billed Charges","neg_dollar:$0.93","1.07","86","","","Percent of Total Billed Charges","neg_dollar:$1.07","0.87","70","","","Percent of Total Billed Charges","neg_dollar:$0.87","0.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.71;103.5% of Medicaid interim rate","1.25","150","","","Percent of Total Billed Charges","neg_dollar:$1.93;150% of Medicaid interim rate","1.00","80","","","Percent of Total Billed Charges","neg_dollar:$1;Percent of Total Billed Charges","1.15","92","","","Percent of Total Billed Charges","neg_dollar:$1.15","0.65","52","","","Percent of Total Billed Charges","neg_dollar:$0.65;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.25","Fee Schedule","","1.00","1.00",""
"SODIUM CHLORIDE 1 G PO TABS","","","77333-844-25","NDC","250","RC","","Facility","Outpatient","1","GM","3.90","3.90","","","","3.90","Fee Schedule","","","","","3.90","Fee Schedule","","","","","3.90","Fee Schedule","","","52","","3.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.35","86","","","Percent of Total Billed Charges","neg_dollar:$3.35","2.73","70","","","Percent of Total Billed Charges","neg_dollar:$2.73","","52","","3.90","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.29;102% of Medicaid interim rate","2.92","75","","","Percent of Total Billed Charges","neg_dollar:$2.92","3.35","86","","","Percent of Total Billed Charges","neg_dollar:$3.35","2.73","70","","","Percent of Total Billed Charges","neg_dollar:$2.73","2.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.22;103.5% of Medicaid interim rate","3.90","150","","","Percent of Total Billed Charges","neg_dollar:$6.02;150% of Medicaid interim rate","3.12","80","","","Percent of Total Billed Charges","neg_dollar:$3.12;Percent of Total Billed Charges","3.58","92","","","Percent of Total Billed Charges","neg_dollar:$3.58","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","3.90","Fee Schedule","","2.00","3.00",""
"SODIUM CHLORIDE 1 G PO TABS","","","77333-844-25","NDC","637","RC","","Facility","Outpatient","1","GM","3.90","3.90","","","","3.90","Fee Schedule","","","","","3.90","Fee Schedule","101% of Medicare Fee Schedule","","","","3.90","Fee Schedule","","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","3.90","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.35","86","","","Percent of Total Billed Charges","neg_dollar:$3.35","2.73","70","","","Percent of Total Billed Charges","neg_dollar:$2.73","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.29;102% of Medicaid interim rate","2.92","75","","","Percent of Total Billed Charges","neg_dollar:$2.92","3.35","86","","","Percent of Total Billed Charges","neg_dollar:$3.35","2.73","70","","","Percent of Total Billed Charges","neg_dollar:$2.73","2.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.22;103.5% of Medicaid interim rate","3.90","150","","","Percent of Total Billed Charges","neg_dollar:$6.02;150% of Medicaid interim rate","3.12","80","","","Percent of Total Billed Charges","neg_dollar:$3.12;Percent of Total Billed Charges","3.58","92","","","Percent of Total Billed Charges","neg_dollar:$3.58","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.02","52","","","Percent of Total Billed Charges","neg_dollar:$2.02;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","3.00",""
"THIAMINE 100 MG TABLET WRAPPER","","","77333-934-25","NDC","250","RC","","Facility","Outpatient","1","EA","2.60","2.60","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","","","2.60","Fee Schedule","","","52","","2.60","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","","52","","2.60","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","1.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.52;102% of Medicaid interim rate","1.95","75","","","Percent of Total Billed Charges","neg_dollar:$1.95","2.23","86","","","Percent of Total Billed Charges","neg_dollar:$2.23","1.81","70","","","Percent of Total Billed Charges","neg_dollar:$1.81","1.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1.48;103.5% of Medicaid interim rate","2.60","150","","","Percent of Total Billed Charges","neg_dollar:$4.01;150% of Medicaid interim rate","2.08","80","","","Percent of Total Billed Charges","neg_dollar:$2.08;Percent of Total Billed Charges","2.39","92","","","Percent of Total Billed Charges","neg_dollar:$2.39","1.35","52","","","Percent of Total Billed Charges","neg_dollar:$1.35;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","2.60","Fee Schedule","","1.00","2.00",""
"VITAMIN B-12 1000 MCG PO TABS","","","77333-938-25","NDC","250","RC","","Facility","Outpatient","1","EA","1.30","1.30","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","","","1.30","Fee Schedule","","","52","","1.30","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;102% Medicare Outpatient Cost to Charge Ratio of 52%","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","","52","","1.30","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","0.76","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.76;102% of Medicaid interim rate","0.97","75","","","Percent of Total Billed Charges","neg_dollar:$0.97","1.11","86","","","Percent of Total Billed Charges","neg_dollar:$1.11","0.90","70","","","Percent of Total Billed Charges","neg_dollar:$0.90","0.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$0.74;103.5% of Medicaid interim rate","1.30","150","","","Percent of Total Billed Charges","neg_dollar:$2;150% of Medicaid interim rate","1.04","80","","","Percent of Total Billed Charges","neg_dollar:$1.04;Percent of Total Billed Charges","1.19","92","","","Percent of Total Billed Charges","neg_dollar:$1.19","0.67","52","","","Percent of Total Billed Charges","neg_dollar:$0.67;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","1.30","Fee Schedule","","1.00","1.00",""
"NA HYALUR & NA CHOND-NA HYALUR 0.55-0.5 ML IO KIT","","","8065-183150","NDC","250","RC","","Facility","Outpatient","1","EA","626.63","626.63","","","","626.63","Fee Schedule","","","","","626.63","Fee Schedule","","","","","626.63","Fee Schedule","","","52","","626.63","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","325.85","52","","","Percent of Total Billed Charges","neg_dollar:$325.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","325.85","52","","","Percent of Total Billed Charges","neg_dollar:$325.85;102% Medicare Outpatient Cost to Charge Ratio of 52%","538.90","86","","","Percent of Total Billed Charges","neg_dollar:$538.90","438.64","70","","","Percent of Total Billed Charges","neg_dollar:$438.64","","52","","626.63","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","368.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$368.14;102% of Medicaid interim rate","469.97","75","","","Percent of Total Billed Charges","neg_dollar:$469.97","538.90","86","","","Percent of Total Billed Charges","neg_dollar:$538.90","438.64","70","","","Percent of Total Billed Charges","neg_dollar:$438.64","357.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$357.18;103.5% of Medicaid interim rate","626.63","150","","","Percent of Total Billed Charges","neg_dollar:$968.81;150% of Medicaid interim rate","501.30","80","","","Percent of Total Billed Charges","neg_dollar:$501.30;Percent of Total Billed Charges","576.50","92","","","Percent of Total Billed Charges","neg_dollar:$576.50","325.85","52","","","Percent of Total Billed Charges","neg_dollar:$325.85;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","626.63","Fee Schedule","","325.00","626.00",""
"NA CHONDROIT SULF-NA HYALURON 20-15 MG/0.5ML IO SOSY","","","8065-183905","NDC","250","RC","","Facility","Outpatient","1","EA","454.55","454.55","","","","454.55","Fee Schedule","","","","","454.55","Fee Schedule","","","","","454.55","Fee Schedule","","","52","","454.55","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","236.36","52","","","Percent of Total Billed Charges","neg_dollar:$236.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","236.36","52","","","Percent of Total Billed Charges","neg_dollar:$236.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","390.91","86","","","Percent of Total Billed Charges","neg_dollar:$390.91","318.18","70","","","Percent of Total Billed Charges","neg_dollar:$318.18","","52","","454.55","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","267.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$267.04;102% of Medicaid interim rate","340.91","75","","","Percent of Total Billed Charges","neg_dollar:$340.91","390.91","86","","","Percent of Total Billed Charges","neg_dollar:$390.91","318.18","70","","","Percent of Total Billed Charges","neg_dollar:$318.18","259.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$259.09;103.5% of Medicaid interim rate","454.55","150","","","Percent of Total Billed Charges","neg_dollar:$702.75;150% of Medicaid interim rate","363.64","80","","","Percent of Total Billed Charges","neg_dollar:$363.64;Percent of Total Billed Charges","418.18","92","","","Percent of Total Billed Charges","neg_dollar:$418.18","236.36","52","","","Percent of Total Billed Charges","neg_dollar:$236.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","454.55","Fee Schedule","","236.00","454.00",""
"LIDOCAINE 5 % EX PTCH","","","82347-0505-4","NDC","250","RC","","Facility","Outpatient","1","EA","4.45","4.45","","","","4.45","Fee Schedule","","","","","4.45","Fee Schedule","","","","","4.45","Fee Schedule","","","52","","4.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.82","86","","","Percent of Total Billed Charges","neg_dollar:$3.82","3.11","70","","","Percent of Total Billed Charges","neg_dollar:$3.11","","52","","4.45","Fee Schedule","105% Medicare Outpatient Cost to Charge Ratio of 52%","2.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.61;102% of Medicaid interim rate","3.33","75","","","Percent of Total Billed Charges","neg_dollar:$3.33","3.82","86","","","Percent of Total Billed Charges","neg_dollar:$3.82","3.11","70","","","Percent of Total Billed Charges","neg_dollar:$3.11","2.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.53;103.5% of Medicaid interim rate","4.45","150","","","Percent of Total Billed Charges","neg_dollar:$6.87;150% of Medicaid interim rate","3.56","80","","","Percent of Total Billed Charges","neg_dollar:$3.56;Percent of Total Billed Charges","4.09","92","","","Percent of Total Billed Charges","neg_dollar:$4.09","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","","","","4.45","Fee Schedule","","2.00","4.00",""
"LIDOCAINE 5 % EX PTCH","","","82347-0505-4","NDC","637","RC","","Facility","Outpatient","1","EA","4.45","4.45","","","","4.45","Fee Schedule","","","","","4.45","Fee Schedule","101% of Medicare Fee Schedule","","","","4.45","Fee Schedule","","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","","52","","4.45","Fee Schedule","102% Medicare Outpatient Cost to Charge Ratio of 52%","3.82","86","","","Percent of Total Billed Charges","neg_dollar:$3.82","3.11","70","","","Percent of Total Billed Charges","neg_dollar:$3.11","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.61;102% of Medicaid interim rate","3.33","75","","","Percent of Total Billed Charges","neg_dollar:$3.33","3.82","86","","","Percent of Total Billed Charges","neg_dollar:$3.82","3.11","70","","","Percent of Total Billed Charges","neg_dollar:$3.11","2.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.53;103.5% of Medicaid interim rate","4.45","150","","","Percent of Total Billed Charges","neg_dollar:$6.87;150% of Medicaid interim rate","3.56","80","","","Percent of Total Billed Charges","neg_dollar:$3.56;Percent of Total Billed Charges","4.09","92","","","Percent of Total Billed Charges","neg_dollar:$4.09","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.31","52","","","Percent of Total Billed Charges","neg_dollar:$2.31;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"SURGERY LEVEL 1 - INIT 30 MIN","","","10010101","CDM","360","RC","","Facility","Outpatient","","","1550","1240.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","806.00","52","","","Percent of Total Billed Charges","neg_dollar:$806;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","806.00","52","","","Percent of Total Billed Charges","neg_dollar:$806;102% Medicare Outpatient Cost to Charge Ratio of 52%","806.00","52","","","Percent of Total Billed Charges","neg_dollar:$806;102% Medicare Outpatient Cost to Charge Ratio of 52%","806.00","52","","","Percent of Total Billed Charges","neg_dollar:$806;102% Medicare Outpatient Cost to Charge Ratio of 52%","1333.00","86","","","Percent of Total Billed Charges","neg_dollar:$1333","1085.00","70","","","Percent of Total Billed Charges","neg_dollar:$1085","806.00","52","","","Percent of Total Billed Charges","neg_dollar:$806;105% Medicare Outpatient Cost to Charge Ratio of 52%","910.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$910.62;102% of Medicaid interim rate","1162.50","75","","","Percent of Total Billed Charges","neg_dollar:$1162.50","1333.00","86","","","Percent of Total Billed Charges","neg_dollar:$1333","1085.00","70","","","Percent of Total Billed Charges","neg_dollar:$1085","883.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$883.49;103.5% of Medicaid interim rate","1550.00","150","","","Percent of Total Billed Charges","neg_dollar:$2396.37;150% of Medicaid interim rate","1240.00","80","","","Percent of Total Billed Charges","neg_dollar:$1240;Percent of Total Billed Charges","1426.00","92","","","Percent of Total Billed Charges","neg_dollar:$1426","806.00","52","","","Percent of Total Billed Charges","neg_dollar:$806;100% Medicare Outpatient Cost to Charge Ratio of 52%","806.00","52","","","Percent of Total Billed Charges","neg_dollar:$806;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1550.00",""
"SURGERY LEVEL 2 - INIT 30 MIN","","","10010102","CDM","360","RC","","Facility","Outpatient","","","2789","2231.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1450.28","52","","","Percent of Total Billed Charges","neg_dollar:$1450.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1450.28","52","","","Percent of Total Billed Charges","neg_dollar:$1450.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","1450.28","52","","","Percent of Total Billed Charges","neg_dollar:$1450.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","1450.28","52","","","Percent of Total Billed Charges","neg_dollar:$1450.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","2398.54","86","","","Percent of Total Billed Charges","neg_dollar:$2398.54","1952.30","70","","","Percent of Total Billed Charges","neg_dollar:$1952.30","1450.28","52","","","Percent of Total Billed Charges","neg_dollar:$1450.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","1638.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1638.53;102% of Medicaid interim rate","2091.75","75","","","Percent of Total Billed Charges","neg_dollar:$2091.75","2398.54","86","","","Percent of Total Billed Charges","neg_dollar:$2398.54","1952.30","70","","","Percent of Total Billed Charges","neg_dollar:$1952.30","1589.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$1589.72;103.5% of Medicaid interim rate","2789.00","150","","","Percent of Total Billed Charges","neg_dollar:$4311.93;150% of Medicaid interim rate","2231.20","80","","","Percent of Total Billed Charges","neg_dollar:$2231.20;Percent of Total Billed Charges","2565.88","92","","","Percent of Total Billed Charges","neg_dollar:$2565.88","1450.28","52","","","Percent of Total Billed Charges","neg_dollar:$1450.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","1450.28","52","","","Percent of Total Billed Charges","neg_dollar:$1450.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2789.00",""
"SURGERY LEVEL 3 - INIT 30 MIN","","","10010103","CDM","360","RC","","Facility","Outpatient","","","4028","3222.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2094.56","52","","","Percent of Total Billed Charges","neg_dollar:$2094.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2094.56","52","","","Percent of Total Billed Charges","neg_dollar:$2094.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","2094.56","52","","","Percent of Total Billed Charges","neg_dollar:$2094.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","2094.56","52","","","Percent of Total Billed Charges","neg_dollar:$2094.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","3464.08","86","","","Percent of Total Billed Charges","neg_dollar:$3464.08","2819.60","70","","","Percent of Total Billed Charges","neg_dollar:$2819.60","2094.56","52","","","Percent of Total Billed Charges","neg_dollar:$2094.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","2366.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$2366.44;102% of Medicaid interim rate","3021.00","75","","","Percent of Total Billed Charges","neg_dollar:$3021","3464.08","86","","","Percent of Total Billed Charges","neg_dollar:$3464.08","2819.60","70","","","Percent of Total Billed Charges","neg_dollar:$2819.60","2295.95","56.99","","","Percent of Total Billed Charges","neg_dollar:$2295.95;103.5% of Medicaid interim rate","4028.00","150","","","Percent of Total Billed Charges","neg_dollar:$6227.48;150% of Medicaid interim rate","3222.40","80","","","Percent of Total Billed Charges","neg_dollar:$3222.40;Percent of Total Billed Charges","3705.76","92","","","Percent of Total Billed Charges","neg_dollar:$3705.76","2094.56","52","","","Percent of Total Billed Charges","neg_dollar:$2094.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","2094.56","52","","","Percent of Total Billed Charges","neg_dollar:$2094.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4028.00",""
"SURGERY LEVEL 4 - INIT 30 MIN","","","10010104","CDM","360","RC","","Facility","Outpatient","","","5268","4214.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2739.36","52","","","Percent of Total Billed Charges","neg_dollar:$2739.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2739.36","52","","","Percent of Total Billed Charges","neg_dollar:$2739.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","2739.36","52","","","Percent of Total Billed Charges","neg_dollar:$2739.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","2739.36","52","","","Percent of Total Billed Charges","neg_dollar:$2739.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","4530.48","86","","","Percent of Total Billed Charges","neg_dollar:$4530.48","3687.60","70","","","Percent of Total Billed Charges","neg_dollar:$3687.60","2739.36","52","","","Percent of Total Billed Charges","neg_dollar:$2739.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","3094.94","56.99","","","Percent of Total Billed Charges","neg_dollar:$3094.94;102% of Medicaid interim rate","3951.00","75","","","Percent of Total Billed Charges","neg_dollar:$3951","4530.48","86","","","Percent of Total Billed Charges","neg_dollar:$4530.48","3687.60","70","","","Percent of Total Billed Charges","neg_dollar:$3687.60","3002.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$3002.75;103.5% of Medicaid interim rate","5268.00","150","","","Percent of Total Billed Charges","neg_dollar:$8144.59;150% of Medicaid interim rate","4214.40","80","","","Percent of Total Billed Charges","neg_dollar:$4214.40;Percent of Total Billed Charges","4846.56","92","","","Percent of Total Billed Charges","neg_dollar:$4846.56","2739.36","52","","","Percent of Total Billed Charges","neg_dollar:$2739.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","2739.36","52","","","Percent of Total Billed Charges","neg_dollar:$2739.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","5268.00",""
"SURGERY LEVEL 5 - INIT 30 MIN","","","10010105","CDM","360","RC","","Facility","Outpatient","","","6509","5207.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","3384.68","52","","","Percent of Total Billed Charges","neg_dollar:$3384.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","3384.68","52","","","Percent of Total Billed Charges","neg_dollar:$3384.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","3384.68","52","","","Percent of Total Billed Charges","neg_dollar:$3384.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","3384.68","52","","","Percent of Total Billed Charges","neg_dollar:$3384.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","5597.74","86","","","Percent of Total Billed Charges","neg_dollar:$5597.74","4556.29","70","","","Percent of Total Billed Charges","neg_dollar:$4556.29","3384.68","52","","","Percent of Total Billed Charges","neg_dollar:$3384.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","3824.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$3824.03;102% of Medicaid interim rate","4881.75","75","","","Percent of Total Billed Charges","neg_dollar:$4881.75","5597.74","86","","","Percent of Total Billed Charges","neg_dollar:$5597.74","4556.29","70","","","Percent of Total Billed Charges","neg_dollar:$4556.29","3710.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$3710.12;103.5% of Medicaid interim rate","6509.00","150","","","Percent of Total Billed Charges","neg_dollar:$10063.23;150% of Medicaid interim rate","5207.20","80","","","Percent of Total Billed Charges","neg_dollar:$5207.20;Percent of Total Billed Charges","5988.28","92","","","Percent of Total Billed Charges","neg_dollar:$5988.28","3384.68","52","","","Percent of Total Billed Charges","neg_dollar:$3384.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","3384.68","52","","","Percent of Total Billed Charges","neg_dollar:$3384.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","6509.00",""
"SURGERY LEVEL 6 - INIT 30 MIN","","","10010106","CDM","360","RC","","Facility","Outpatient","","","7747","6197.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","4028.44","52","","","Percent of Total Billed Charges","neg_dollar:$4028.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","4028.44","52","","","Percent of Total Billed Charges","neg_dollar:$4028.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","4028.44","52","","","Percent of Total Billed Charges","neg_dollar:$4028.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","4028.44","52","","","Percent of Total Billed Charges","neg_dollar:$4028.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","6662.42","86","","","Percent of Total Billed Charges","neg_dollar:$6662.42","5422.90","70","","","Percent of Total Billed Charges","neg_dollar:$5422.90","4028.44","52","","","Percent of Total Billed Charges","neg_dollar:$4028.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","4551.35","56.99","","","Percent of Total Billed Charges","neg_dollar:$4551.35;102% of Medicaid interim rate","5810.25","75","","","Percent of Total Billed Charges","neg_dollar:$5810.25","6662.42","86","","","Percent of Total Billed Charges","neg_dollar:$6662.42","5422.90","70","","","Percent of Total Billed Charges","neg_dollar:$5422.90","4415.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$4415.79;103.5% of Medicaid interim rate","7747.00","150","","","Percent of Total Billed Charges","neg_dollar:$11977.24;150% of Medicaid interim rate","6197.60","80","","","Percent of Total Billed Charges","neg_dollar:$6197.60;Percent of Total Billed Charges","7127.24","92","","","Percent of Total Billed Charges","neg_dollar:$7127.24","4028.44","52","","","Percent of Total Billed Charges","neg_dollar:$4028.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","4028.44","52","","","Percent of Total Billed Charges","neg_dollar:$4028.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","7747.00",""
"OB BASE LEVEL 6","","","10070006","CDM","360","RC","","Facility","Outpatient","","","3214","2571.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1671.28","52","","","Percent of Total Billed Charges","neg_dollar:$1671.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1671.28","52","","","Percent of Total Billed Charges","neg_dollar:$1671.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","1671.28","52","","","Percent of Total Billed Charges","neg_dollar:$1671.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","1671.28","52","","","Percent of Total Billed Charges","neg_dollar:$1671.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","2764.04","86","","","Percent of Total Billed Charges","neg_dollar:$2764.04","2249.79","70","","","Percent of Total Billed Charges","neg_dollar:$2249.79","1671.28","52","","","Percent of Total Billed Charges","neg_dollar:$1671.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","1888.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$1888.22;102% of Medicaid interim rate","2410.50","75","","","Percent of Total Billed Charges","neg_dollar:$2410.50","2764.04","86","","","Percent of Total Billed Charges","neg_dollar:$2764.04","2249.79","70","","","Percent of Total Billed Charges","neg_dollar:$2249.79","1831.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$1831.97;103.5% of Medicaid interim rate","3214.00","150","","","Percent of Total Billed Charges","neg_dollar:$4969;150% of Medicaid interim rate","2571.20","80","","","Percent of Total Billed Charges","neg_dollar:$2571.20;Percent of Total Billed Charges","2956.88","92","","","Percent of Total Billed Charges","neg_dollar:$2956.88","1671.28","52","","","Percent of Total Billed Charges","neg_dollar:$1671.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","1671.28","52","","","Percent of Total Billed Charges","neg_dollar:$1671.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3214.00",""
"OB ADD-ON","","","10070015","CDM","721","RC","","Facility","Outpatient","","","1829","1463.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","1572.94","86","","","Percent of Total Billed Charges","neg_dollar:$1572.94","1280.30","70","","","Percent of Total Billed Charges","neg_dollar:$1280.30","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","1074.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1074.53;102% of Medicaid interim rate","1371.75","75","","","Percent of Total Billed Charges","neg_dollar:$1371.75","1572.94","86","","","Percent of Total Billed Charges","neg_dollar:$1572.94","1280.30","70","","","Percent of Total Billed Charges","neg_dollar:$1280.30","1042.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$1042.53;103.5% of Medicaid interim rate","1829.00","150","","","Percent of Total Billed Charges","neg_dollar:$2827.72;150% of Medicaid interim rate","1463.20","80","","","Percent of Total Billed Charges","neg_dollar:$1463.20;Percent of Total Billed Charges","1682.68","92","","","Percent of Total Billed Charges","neg_dollar:$1682.68","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","951.08","52","","","Percent of Total Billed Charges","neg_dollar:$951.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1829.00",""
"SURGERY LEVEL 1 - EA ADDTL 15 MIN","","","20020101","CDM","360","RC","","Facility","Outpatient","","","223","178.40","223.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","115.96","52","","","Percent of Total Billed Charges","neg_dollar:$115.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","223.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","115.96","52","","","Percent of Total Billed Charges","neg_dollar:$115.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","115.96","52","","","Percent of Total Billed Charges","neg_dollar:$115.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","115.96","52","","","Percent of Total Billed Charges","neg_dollar:$115.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","191.78","86","","","Percent of Total Billed Charges","neg_dollar:$191.78","156.10","70","","","Percent of Total Billed Charges","neg_dollar:$156.10","115.96","52","","","Percent of Total Billed Charges","neg_dollar:$115.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","131.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$131.01;102% of Medicaid interim rate","167.25","75","","","Percent of Total Billed Charges","neg_dollar:$167.25","191.78","86","","","Percent of Total Billed Charges","neg_dollar:$191.78","156.10","70","","","Percent of Total Billed Charges","neg_dollar:$156.10","127.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$127.10;103.5% of Medicaid interim rate","223.00","150","","","Percent of Total Billed Charges","neg_dollar:$344.76;150% of Medicaid interim rate","178.40","80","","","Percent of Total Billed Charges","neg_dollar:$178.40;Percent of Total Billed Charges","205.16","92","","","Percent of Total Billed Charges","neg_dollar:$205.16","115.96","52","","","Percent of Total Billed Charges","neg_dollar:$115.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","115.96","52","","","Percent of Total Billed Charges","neg_dollar:$115.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","115.00","223.00",""
"SURGERY LEVEL 2 - EA ADDTL 15 MIN","","","20020102","CDM","360","RC","","Facility","Outpatient","","","383","306.40","383.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","199.16","52","","","Percent of Total Billed Charges","neg_dollar:$199.16;101% Medicare Outpatient Cost to Charge Ratio of 52%","383.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","199.16","52","","","Percent of Total Billed Charges","neg_dollar:$199.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","199.16","52","","","Percent of Total Billed Charges","neg_dollar:$199.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","199.16","52","","","Percent of Total Billed Charges","neg_dollar:$199.16;102% Medicare Outpatient Cost to Charge Ratio of 52%","329.38","86","","","Percent of Total Billed Charges","neg_dollar:$329.38","268.09","70","","","Percent of Total Billed Charges","neg_dollar:$268.09","199.16","52","","","Percent of Total Billed Charges","neg_dollar:$199.16;105% Medicare Outpatient Cost to Charge Ratio of 52%","225.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$225.01;102% of Medicaid interim rate","287.25","75","","","Percent of Total Billed Charges","neg_dollar:$287.25","329.38","86","","","Percent of Total Billed Charges","neg_dollar:$329.38","268.09","70","","","Percent of Total Billed Charges","neg_dollar:$268.09","218.30","56.99","","","Percent of Total Billed Charges","neg_dollar:$218.30;103.5% of Medicaid interim rate","383.00","150","","","Percent of Total Billed Charges","neg_dollar:$592.13;150% of Medicaid interim rate","306.40","80","","","Percent of Total Billed Charges","neg_dollar:$306.40;Percent of Total Billed Charges","352.36","92","","","Percent of Total Billed Charges","neg_dollar:$352.36","199.16","52","","","Percent of Total Billed Charges","neg_dollar:$199.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","199.16","52","","","Percent of Total Billed Charges","neg_dollar:$199.16;100% Medicare Outpatient Cost to Charge Ratio of 52%","199.00","383.00",""
"SURGERY LEVEL 3 - EA ADDTL 15 MIN","","","20020103","CDM","360","RC","","Facility","Outpatient","","","543","434.40","543.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","282.36","52","","","Percent of Total Billed Charges","neg_dollar:$282.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","543.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","282.36","52","","","Percent of Total Billed Charges","neg_dollar:$282.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","282.36","52","","","Percent of Total Billed Charges","neg_dollar:$282.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","282.36","52","","","Percent of Total Billed Charges","neg_dollar:$282.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","466.98","86","","","Percent of Total Billed Charges","neg_dollar:$466.98","380.09","70","","","Percent of Total Billed Charges","neg_dollar:$380.09","282.36","52","","","Percent of Total Billed Charges","neg_dollar:$282.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","319.01","56.99","","","Percent of Total Billed Charges","neg_dollar:$319.01;102% of Medicaid interim rate","407.25","75","","","Percent of Total Billed Charges","neg_dollar:$407.25","466.98","86","","","Percent of Total Billed Charges","neg_dollar:$466.98","380.09","70","","","Percent of Total Billed Charges","neg_dollar:$380.09","309.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$309.51;103.5% of Medicaid interim rate","543.00","150","","","Percent of Total Billed Charges","neg_dollar:$839.50;150% of Medicaid interim rate","434.40","80","","","Percent of Total Billed Charges","neg_dollar:$434.40;Percent of Total Billed Charges","499.56","92","","","Percent of Total Billed Charges","neg_dollar:$499.56","282.36","52","","","Percent of Total Billed Charges","neg_dollar:$282.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","282.36","52","","","Percent of Total Billed Charges","neg_dollar:$282.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","282.00","543.00",""
"SURGERY LEVEL 4 - EA ADDTL 15 MIN","","","20020104","CDM","360","RC","","Facility","Outpatient","","","705","564.00","705.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","705.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","606.30","86","","","Percent of Total Billed Charges","neg_dollar:$606.30","493.49","70","","","Percent of Total Billed Charges","neg_dollar:$493.49","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","414.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$414.18;102% of Medicaid interim rate","528.75","75","","","Percent of Total Billed Charges","neg_dollar:$528.75","606.30","86","","","Percent of Total Billed Charges","neg_dollar:$606.30","493.49","70","","","Percent of Total Billed Charges","neg_dollar:$493.49","401.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$401.84;103.5% of Medicaid interim rate","705.00","150","","","Percent of Total Billed Charges","neg_dollar:$1089.96;150% of Medicaid interim rate","564.00","80","","","Percent of Total Billed Charges","neg_dollar:$564;Percent of Total Billed Charges","648.60","92","","","Percent of Total Billed Charges","neg_dollar:$648.60","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.00","705.00",""
"SURGERY LEVEL 5 - EA ADDTL 15 MIN","","","20020105","CDM","360","RC","","Facility","Outpatient","","","866","692.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","450.32","52","","","Percent of Total Billed Charges","neg_dollar:$450.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","450.32","52","","","Percent of Total Billed Charges","neg_dollar:$450.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","450.32","52","","","Percent of Total Billed Charges","neg_dollar:$450.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","450.32","52","","","Percent of Total Billed Charges","neg_dollar:$450.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","744.76","86","","","Percent of Total Billed Charges","neg_dollar:$744.76","606.19","70","","","Percent of Total Billed Charges","neg_dollar:$606.19","450.32","52","","","Percent of Total Billed Charges","neg_dollar:$450.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","508.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$508.77;102% of Medicaid interim rate","649.50","75","","","Percent of Total Billed Charges","neg_dollar:$649.50","744.76","86","","","Percent of Total Billed Charges","neg_dollar:$744.76","606.19","70","","","Percent of Total Billed Charges","neg_dollar:$606.19","493.61","56.99","","","Percent of Total Billed Charges","neg_dollar:$493.61;103.5% of Medicaid interim rate","866.00","150","","","Percent of Total Billed Charges","neg_dollar:$1338.87;150% of Medicaid interim rate","692.80","80","","","Percent of Total Billed Charges","neg_dollar:$692.80;Percent of Total Billed Charges","796.72","92","","","Percent of Total Billed Charges","neg_dollar:$796.72","450.32","52","","","Percent of Total Billed Charges","neg_dollar:$450.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","450.32","52","","","Percent of Total Billed Charges","neg_dollar:$450.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","450.00","866.00",""
"SURGERY LEVEL 6 - EA ADDTL 15 MIN","","","20020106","CDM","360","RC","","Facility","Outpatient","","","1026","820.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","533.52","52","","","Percent of Total Billed Charges","neg_dollar:$533.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","533.52","52","","","Percent of Total Billed Charges","neg_dollar:$533.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","533.52","52","","","Percent of Total Billed Charges","neg_dollar:$533.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","533.52","52","","","Percent of Total Billed Charges","neg_dollar:$533.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","882.36","86","","","Percent of Total Billed Charges","neg_dollar:$882.36","718.19","70","","","Percent of Total Billed Charges","neg_dollar:$718.19","533.52","52","","","Percent of Total Billed Charges","neg_dollar:$533.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","602.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$602.77;102% of Medicaid interim rate","769.50","75","","","Percent of Total Billed Charges","neg_dollar:$769.50","882.36","86","","","Percent of Total Billed Charges","neg_dollar:$882.36","718.19","70","","","Percent of Total Billed Charges","neg_dollar:$718.19","584.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$584.81;103.5% of Medicaid interim rate","1026.00","150","","","Percent of Total Billed Charges","neg_dollar:$1586.24;150% of Medicaid interim rate","820.80","80","","","Percent of Total Billed Charges","neg_dollar:$820.80;Percent of Total Billed Charges","943.92","92","","","Percent of Total Billed Charges","neg_dollar:$943.92","533.52","52","","","Percent of Total Billed Charges","neg_dollar:$533.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","533.52","52","","","Percent of Total Billed Charges","neg_dollar:$533.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","533.00","1026.00",""
"OB PER MIN LEVEL 6","","","20070006","CDM","360","RC","","Facility","Outpatient","","","38","30.40","38.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","38.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","32.68","86","","","Percent of Total Billed Charges","neg_dollar:$32.68","26.59","70","","","Percent of Total Billed Charges","neg_dollar:$26.59","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","22.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$22.32;102% of Medicaid interim rate","28.50","75","","","Percent of Total Billed Charges","neg_dollar:$28.50","32.68","86","","","Percent of Total Billed Charges","neg_dollar:$32.68","26.59","70","","","Percent of Total Billed Charges","neg_dollar:$26.59","21.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$21.65;103.5% of Medicaid interim rate","38.00","150","","","Percent of Total Billed Charges","neg_dollar:$58.74;150% of Medicaid interim rate","30.40","80","","","Percent of Total Billed Charges","neg_dollar:$30.40;Percent of Total Billed Charges","34.96","92","","","Percent of Total Billed Charges","neg_dollar:$34.96","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","19.76","52","","","Percent of Total Billed Charges","neg_dollar:$19.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","19.00","38.00",""
"OXYGEN INITIAL DAY","","","27003280","CDM","270","RC","","Facility","Outpatient","","","826","660.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","429.52","52","","","Percent of Total Billed Charges","neg_dollar:$429.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","429.52","52","","","Percent of Total Billed Charges","neg_dollar:$429.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","429.52","52","","","Percent of Total Billed Charges","neg_dollar:$429.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","429.52","52","","","Percent of Total Billed Charges","neg_dollar:$429.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","710.36","86","","","Percent of Total Billed Charges","neg_dollar:$710.36","578.19","70","","","Percent of Total Billed Charges","neg_dollar:$578.19","429.52","52","","","Percent of Total Billed Charges","neg_dollar:$429.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","485.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$485.27;102% of Medicaid interim rate","619.50","75","","","Percent of Total Billed Charges","neg_dollar:$619.50","710.36","86","","","Percent of Total Billed Charges","neg_dollar:$710.36","578.19","70","","","Percent of Total Billed Charges","neg_dollar:$578.19","470.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$470.81;103.5% of Medicaid interim rate","826.00","150","","","Percent of Total Billed Charges","neg_dollar:$1277.03;150% of Medicaid interim rate","660.80","80","","","Percent of Total Billed Charges","neg_dollar:$660.80;Percent of Total Billed Charges","759.92","92","","","Percent of Total Billed Charges","neg_dollar:$759.92","429.52","52","","","Percent of Total Billed Charges","neg_dollar:$429.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","429.52","52","","","Percent of Total Billed Charges","neg_dollar:$429.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","429.00","826.00",""
"OXYGEN SUBQ DAY","","","27003281","CDM","270","RC","","Facility","Outpatient","","","799","639.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","415.48","52","","","Percent of Total Billed Charges","neg_dollar:$415.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","799.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","415.48","52","","","Percent of Total Billed Charges","neg_dollar:$415.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","415.48","52","","","Percent of Total Billed Charges","neg_dollar:$415.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","415.48","52","","","Percent of Total Billed Charges","neg_dollar:$415.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","687.14","86","","","Percent of Total Billed Charges","neg_dollar:$687.14","559.30","70","","","Percent of Total Billed Charges","neg_dollar:$559.30","415.48","52","","","Percent of Total Billed Charges","neg_dollar:$415.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","469.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$469.41;102% of Medicaid interim rate","599.25","75","","","Percent of Total Billed Charges","neg_dollar:$599.25","687.14","86","","","Percent of Total Billed Charges","neg_dollar:$687.14","559.30","70","","","Percent of Total Billed Charges","neg_dollar:$559.30","455.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$455.42;103.5% of Medicaid interim rate","799.00","150","","","Percent of Total Billed Charges","neg_dollar:$1235.29;150% of Medicaid interim rate","639.20","80","","","Percent of Total Billed Charges","neg_dollar:$639.20;Percent of Total Billed Charges","735.08","92","","","Percent of Total Billed Charges","neg_dollar:$735.08","415.48","52","","","Percent of Total Billed Charges","neg_dollar:$415.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","415.48","52","","","Percent of Total Billed Charges","neg_dollar:$415.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","415.00","799.00",""
"MED/SURG SUPPLY LEVEL 1","","","27100001","CDM","270","RC","","Facility","Outpatient","","","21","16.80","21.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","10.92","52","","","Percent of Total Billed Charges","neg_dollar:$10.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","21.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","10.92","52","","","Percent of Total Billed Charges","neg_dollar:$10.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.92","52","","","Percent of Total Billed Charges","neg_dollar:$10.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","10.92","52","","","Percent of Total Billed Charges","neg_dollar:$10.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","18.06","86","","","Percent of Total Billed Charges","neg_dollar:$18.06","14.70","70","","","Percent of Total Billed Charges","neg_dollar:$14.70","10.92","52","","","Percent of Total Billed Charges","neg_dollar:$10.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","12.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$12.33;102% of Medicaid interim rate","15.75","75","","","Percent of Total Billed Charges","neg_dollar:$15.75","18.06","86","","","Percent of Total Billed Charges","neg_dollar:$18.06","14.70","70","","","Percent of Total Billed Charges","neg_dollar:$14.70","11.96","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.96;103.5% of Medicaid interim rate","21.00","150","","","Percent of Total Billed Charges","neg_dollar:$32.46;150% of Medicaid interim rate","16.80","80","","","Percent of Total Billed Charges","neg_dollar:$16.80;Percent of Total Billed Charges","19.32","92","","","Percent of Total Billed Charges","neg_dollar:$19.32","10.92","52","","","Percent of Total Billed Charges","neg_dollar:$10.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.92","52","","","Percent of Total Billed Charges","neg_dollar:$10.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","10.00","21.00",""
"MED/SURG SUPPLY LEVEL 2","","","27100002","CDM","270","RC","","Facility","Outpatient","","","53","42.40","53.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","53.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","45.58","86","","","Percent of Total Billed Charges","neg_dollar:$45.58","37.09","70","","","Percent of Total Billed Charges","neg_dollar:$37.09","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","31.13","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.13;102% of Medicaid interim rate","39.75","75","","","Percent of Total Billed Charges","neg_dollar:$39.75","45.58","86","","","Percent of Total Billed Charges","neg_dollar:$45.58","37.09","70","","","Percent of Total Billed Charges","neg_dollar:$37.09","30.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.20;103.5% of Medicaid interim rate","53.00","150","","","Percent of Total Billed Charges","neg_dollar:$81.94;150% of Medicaid interim rate","42.40","80","","","Percent of Total Billed Charges","neg_dollar:$42.40;Percent of Total Billed Charges","48.76","92","","","Percent of Total Billed Charges","neg_dollar:$48.76","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.56","52","","","Percent of Total Billed Charges","neg_dollar:$27.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.00","53.00",""
"MED/SURG SUPPLY LEVEL 3","","","27100003","CDM","270","RC","","Facility","Outpatient","","","109","87.20","109.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","56.68","52","","","Percent of Total Billed Charges","neg_dollar:$56.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","109.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","56.68","52","","","Percent of Total Billed Charges","neg_dollar:$56.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","56.68","52","","","Percent of Total Billed Charges","neg_dollar:$56.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","56.68","52","","","Percent of Total Billed Charges","neg_dollar:$56.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","93.74","86","","","Percent of Total Billed Charges","neg_dollar:$93.74","76.30","70","","","Percent of Total Billed Charges","neg_dollar:$76.30","56.68","52","","","Percent of Total Billed Charges","neg_dollar:$56.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","64.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.03;102% of Medicaid interim rate","81.75","75","","","Percent of Total Billed Charges","neg_dollar:$81.75","93.74","86","","","Percent of Total Billed Charges","neg_dollar:$93.74","76.30","70","","","Percent of Total Billed Charges","neg_dollar:$76.30","62.12","56.99","","","Percent of Total Billed Charges","neg_dollar:$62.12;103.5% of Medicaid interim rate","109.00","150","","","Percent of Total Billed Charges","neg_dollar:$168.51;150% of Medicaid interim rate","87.20","80","","","Percent of Total Billed Charges","neg_dollar:$87.20;Percent of Total Billed Charges","100.28","92","","","Percent of Total Billed Charges","neg_dollar:$100.28","56.68","52","","","Percent of Total Billed Charges","neg_dollar:$56.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","56.68","52","","","Percent of Total Billed Charges","neg_dollar:$56.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","56.00","109.00",""
"MED/SURG SUPPLY LEVEL 4","","","27100004","CDM","270","RC","","Facility","Outpatient","","","164","131.20","164.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","85.28","52","","","Percent of Total Billed Charges","neg_dollar:$85.28;101% Medicare Outpatient Cost to Charge Ratio of 52%","164.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","85.28","52","","","Percent of Total Billed Charges","neg_dollar:$85.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","85.28","52","","","Percent of Total Billed Charges","neg_dollar:$85.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","85.28","52","","","Percent of Total Billed Charges","neg_dollar:$85.28;102% Medicare Outpatient Cost to Charge Ratio of 52%","141.04","86","","","Percent of Total Billed Charges","neg_dollar:$141.04","114.80","70","","","Percent of Total Billed Charges","neg_dollar:$114.80","85.28","52","","","Percent of Total Billed Charges","neg_dollar:$85.28;105% Medicare Outpatient Cost to Charge Ratio of 52%","96.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$96.34;102% of Medicaid interim rate","123.00","75","","","Percent of Total Billed Charges","neg_dollar:$123","141.04","86","","","Percent of Total Billed Charges","neg_dollar:$141.04","114.80","70","","","Percent of Total Billed Charges","neg_dollar:$114.80","93.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$93.47;103.5% of Medicaid interim rate","164.00","150","","","Percent of Total Billed Charges","neg_dollar:$253.55;150% of Medicaid interim rate","131.20","80","","","Percent of Total Billed Charges","neg_dollar:$131.20;Percent of Total Billed Charges","150.88","92","","","Percent of Total Billed Charges","neg_dollar:$150.88","85.28","52","","","Percent of Total Billed Charges","neg_dollar:$85.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","85.28","52","","","Percent of Total Billed Charges","neg_dollar:$85.28;100% Medicare Outpatient Cost to Charge Ratio of 52%","85.00","164.00",""
"MED/SURG SUPPLY LEVEL 5","","","27100005","CDM","270","RC","","Facility","Outpatient","","","254","203.20","254.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","132.08","52","","","Percent of Total Billed Charges","neg_dollar:$132.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","254.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","132.08","52","","","Percent of Total Billed Charges","neg_dollar:$132.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","132.08","52","","","Percent of Total Billed Charges","neg_dollar:$132.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","132.08","52","","","Percent of Total Billed Charges","neg_dollar:$132.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","218.44","86","","","Percent of Total Billed Charges","neg_dollar:$218.44","177.79","70","","","Percent of Total Billed Charges","neg_dollar:$177.79","132.08","52","","","Percent of Total Billed Charges","neg_dollar:$132.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","149.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$149.22;102% of Medicaid interim rate","190.50","75","","","Percent of Total Billed Charges","neg_dollar:$190.50","218.44","86","","","Percent of Total Billed Charges","neg_dollar:$218.44","177.79","70","","","Percent of Total Billed Charges","neg_dollar:$177.79","144.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$144.78;103.5% of Medicaid interim rate","254.00","150","","","Percent of Total Billed Charges","neg_dollar:$392.69;150% of Medicaid interim rate","203.20","80","","","Percent of Total Billed Charges","neg_dollar:$203.20;Percent of Total Billed Charges","233.68","92","","","Percent of Total Billed Charges","neg_dollar:$233.68","132.08","52","","","Percent of Total Billed Charges","neg_dollar:$132.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","132.08","52","","","Percent of Total Billed Charges","neg_dollar:$132.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","132.00","254.00",""
"MED/SURG SUPPLY LEVEL 6","","","27100006","CDM","270","RC","","Facility","Outpatient","","","319","255.20","319.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","319.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","274.34","86","","","Percent of Total Billed Charges","neg_dollar:$274.34","223.29","70","","","Percent of Total Billed Charges","neg_dollar:$223.29","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","187.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$187.41;102% of Medicaid interim rate","239.25","75","","","Percent of Total Billed Charges","neg_dollar:$239.25","274.34","86","","","Percent of Total Billed Charges","neg_dollar:$274.34","223.29","70","","","Percent of Total Billed Charges","neg_dollar:$223.29","181.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$181.82;103.5% of Medicaid interim rate","319.00","150","","","Percent of Total Billed Charges","neg_dollar:$493.18;150% of Medicaid interim rate","255.20","80","","","Percent of Total Billed Charges","neg_dollar:$255.20;Percent of Total Billed Charges","293.48","92","","","Percent of Total Billed Charges","neg_dollar:$293.48","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","165.00","319.00",""
"MED/SURG SUPPLY LEVEL 7","","","27100007","CDM","270","RC","","Facility","Outpatient","","","319","255.20","319.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","319.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","274.34","86","","","Percent of Total Billed Charges","neg_dollar:$274.34","223.29","70","","","Percent of Total Billed Charges","neg_dollar:$223.29","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","187.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$187.41;102% of Medicaid interim rate","239.25","75","","","Percent of Total Billed Charges","neg_dollar:$239.25","274.34","86","","","Percent of Total Billed Charges","neg_dollar:$274.34","223.29","70","","","Percent of Total Billed Charges","neg_dollar:$223.29","181.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$181.82;103.5% of Medicaid interim rate","319.00","150","","","Percent of Total Billed Charges","neg_dollar:$493.18;150% of Medicaid interim rate","255.20","80","","","Percent of Total Billed Charges","neg_dollar:$255.20;Percent of Total Billed Charges","293.48","92","","","Percent of Total Billed Charges","neg_dollar:$293.48","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","165.88","52","","","Percent of Total Billed Charges","neg_dollar:$165.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","165.00","319.00",""
"MED/SURG SUPPLY LEVEL 8","","","27100008","CDM","270","RC","","Facility","Outpatient","","","365","292.00","365.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","365.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","313.90","86","","","Percent of Total Billed Charges","neg_dollar:$313.90","255.49","70","","","Percent of Total Billed Charges","neg_dollar:$255.49","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","214.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$214.43;102% of Medicaid interim rate","273.75","75","","","Percent of Total Billed Charges","neg_dollar:$273.75","313.90","86","","","Percent of Total Billed Charges","neg_dollar:$313.90","255.49","70","","","Percent of Total Billed Charges","neg_dollar:$255.49","208.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$208.04;103.5% of Medicaid interim rate","365.00","150","","","Percent of Total Billed Charges","neg_dollar:$564.30;150% of Medicaid interim rate","292.00","80","","","Percent of Total Billed Charges","neg_dollar:$292;Percent of Total Billed Charges","335.80","92","","","Percent of Total Billed Charges","neg_dollar:$335.80","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","189.80","52","","","Percent of Total Billed Charges","neg_dollar:$189.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","189.00","365.00",""
"MED/SURG SUPPLY LEVEL 9","","","27100009","CDM","270","RC","","Facility","Outpatient","","","378","302.40","378.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","196.56","52","","","Percent of Total Billed Charges","neg_dollar:$196.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","378.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","196.56","52","","","Percent of Total Billed Charges","neg_dollar:$196.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","196.56","52","","","Percent of Total Billed Charges","neg_dollar:$196.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","196.56","52","","","Percent of Total Billed Charges","neg_dollar:$196.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","325.08","86","","","Percent of Total Billed Charges","neg_dollar:$325.08","264.59","70","","","Percent of Total Billed Charges","neg_dollar:$264.59","196.56","52","","","Percent of Total Billed Charges","neg_dollar:$196.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","222.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$222.07;102% of Medicaid interim rate","283.50","75","","","Percent of Total Billed Charges","neg_dollar:$283.50","325.08","86","","","Percent of Total Billed Charges","neg_dollar:$325.08","264.59","70","","","Percent of Total Billed Charges","neg_dollar:$264.59","215.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$215.45;103.5% of Medicaid interim rate","378.00","150","","","Percent of Total Billed Charges","neg_dollar:$584.40;150% of Medicaid interim rate","302.40","80","","","Percent of Total Billed Charges","neg_dollar:$302.40;Percent of Total Billed Charges","347.76","92","","","Percent of Total Billed Charges","neg_dollar:$347.76","196.56","52","","","Percent of Total Billed Charges","neg_dollar:$196.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","196.56","52","","","Percent of Total Billed Charges","neg_dollar:$196.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","196.00","378.00",""
"MED/SURG SUPPLY LEVEL 10","","","27100010","CDM","270","RC","","Facility","Outpatient","","","457","365.60","457.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","457.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","393.02","86","","","Percent of Total Billed Charges","neg_dollar:$393.02","319.90","70","","","Percent of Total Billed Charges","neg_dollar:$319.90","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","268.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$268.48;102% of Medicaid interim rate","342.75","75","","","Percent of Total Billed Charges","neg_dollar:$342.75","393.02","86","","","Percent of Total Billed Charges","neg_dollar:$393.02","319.90","70","","","Percent of Total Billed Charges","neg_dollar:$319.90","260.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$260.48;103.5% of Medicaid interim rate","457.00","150","","","Percent of Total Billed Charges","neg_dollar:$706.54;150% of Medicaid interim rate","365.60","80","","","Percent of Total Billed Charges","neg_dollar:$365.60;Percent of Total Billed Charges","420.44","92","","","Percent of Total Billed Charges","neg_dollar:$420.44","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","237.64","52","","","Percent of Total Billed Charges","neg_dollar:$237.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","237.00","457.00",""
"MED/SURG SUPPLY LEVEL 11","","","27100011","CDM","270","RC","","Facility","Outpatient","","","504","403.20","504.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","262.08","52","","","Percent of Total Billed Charges","neg_dollar:$262.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","504.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","262.08","52","","","Percent of Total Billed Charges","neg_dollar:$262.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","262.08","52","","","Percent of Total Billed Charges","neg_dollar:$262.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","262.08","52","","","Percent of Total Billed Charges","neg_dollar:$262.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","433.44","86","","","Percent of Total Billed Charges","neg_dollar:$433.44","352.79","70","","","Percent of Total Billed Charges","neg_dollar:$352.79","262.08","52","","","Percent of Total Billed Charges","neg_dollar:$262.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","296.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$296.09;102% of Medicaid interim rate","378.00","75","","","Percent of Total Billed Charges","neg_dollar:$378","433.44","86","","","Percent of Total Billed Charges","neg_dollar:$433.44","352.79","70","","","Percent of Total Billed Charges","neg_dollar:$352.79","287.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$287.28;103.5% of Medicaid interim rate","504.00","150","","","Percent of Total Billed Charges","neg_dollar:$779.20;150% of Medicaid interim rate","403.20","80","","","Percent of Total Billed Charges","neg_dollar:$403.20;Percent of Total Billed Charges","463.68","92","","","Percent of Total Billed Charges","neg_dollar:$463.68","262.08","52","","","Percent of Total Billed Charges","neg_dollar:$262.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","262.08","52","","","Percent of Total Billed Charges","neg_dollar:$262.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","262.00","504.00",""
"MED/SURG SUPPLY LEVEL 12","","","27100012","CDM","270","RC","","Facility","Outpatient","","","586","468.80","586.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","304.72","52","","","Percent of Total Billed Charges","neg_dollar:$304.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","586.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","304.72","52","","","Percent of Total Billed Charges","neg_dollar:$304.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","304.72","52","","","Percent of Total Billed Charges","neg_dollar:$304.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","304.72","52","","","Percent of Total Billed Charges","neg_dollar:$304.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","503.96","86","","","Percent of Total Billed Charges","neg_dollar:$503.96","410.20","70","","","Percent of Total Billed Charges","neg_dollar:$410.20","304.72","52","","","Percent of Total Billed Charges","neg_dollar:$304.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","344.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$344.27;102% of Medicaid interim rate","439.50","75","","","Percent of Total Billed Charges","neg_dollar:$439.50","503.96","86","","","Percent of Total Billed Charges","neg_dollar:$503.96","410.20","70","","","Percent of Total Billed Charges","neg_dollar:$410.20","334.02","56.99","","","Percent of Total Billed Charges","neg_dollar:$334.02;103.5% of Medicaid interim rate","586.00","150","","","Percent of Total Billed Charges","neg_dollar:$905.98;150% of Medicaid interim rate","468.80","80","","","Percent of Total Billed Charges","neg_dollar:$468.80;Percent of Total Billed Charges","539.12","92","","","Percent of Total Billed Charges","neg_dollar:$539.12","304.72","52","","","Percent of Total Billed Charges","neg_dollar:$304.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","304.72","52","","","Percent of Total Billed Charges","neg_dollar:$304.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","304.00","586.00",""
"MED/SURG SUPPLY LEVEL 13","","","27100013","CDM","270","RC","","Facility","Outpatient","","","712","569.60","712.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","370.24","52","","","Percent of Total Billed Charges","neg_dollar:$370.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","712.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","370.24","52","","","Percent of Total Billed Charges","neg_dollar:$370.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","370.24","52","","","Percent of Total Billed Charges","neg_dollar:$370.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","370.24","52","","","Percent of Total Billed Charges","neg_dollar:$370.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","612.31","86","","","Percent of Total Billed Charges","neg_dollar:$612.31","498.40","70","","","Percent of Total Billed Charges","neg_dollar:$498.40","370.24","52","","","Percent of Total Billed Charges","neg_dollar:$370.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","418.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$418.29;102% of Medicaid interim rate","534.00","75","","","Percent of Total Billed Charges","neg_dollar:$534","612.31","86","","","Percent of Total Billed Charges","neg_dollar:$612.31","498.40","70","","","Percent of Total Billed Charges","neg_dollar:$498.40","405.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$405.84;103.5% of Medicaid interim rate","712.00","150","","","Percent of Total Billed Charges","neg_dollar:$1100.78;150% of Medicaid interim rate","569.60","80","","","Percent of Total Billed Charges","neg_dollar:$569.60;Percent of Total Billed Charges","655.04","92","","","Percent of Total Billed Charges","neg_dollar:$655.04","370.24","52","","","Percent of Total Billed Charges","neg_dollar:$370.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","370.24","52","","","Percent of Total Billed Charges","neg_dollar:$370.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","370.00","712.00",""
"MED/SURG SUPPLY LEVEL 14","","","27100014","CDM","270","RC","","Facility","Outpatient","","","825","660.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","429.00","52","","","Percent of Total Billed Charges","neg_dollar:$429;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","429.00","52","","","Percent of Total Billed Charges","neg_dollar:$429;102% Medicare Outpatient Cost to Charge Ratio of 52%","429.00","52","","","Percent of Total Billed Charges","neg_dollar:$429;102% Medicare Outpatient Cost to Charge Ratio of 52%","429.00","52","","","Percent of Total Billed Charges","neg_dollar:$429;102% Medicare Outpatient Cost to Charge Ratio of 52%","709.50","86","","","Percent of Total Billed Charges","neg_dollar:$709.50","577.50","70","","","Percent of Total Billed Charges","neg_dollar:$577.50","429.00","52","","","Percent of Total Billed Charges","neg_dollar:$429;105% Medicare Outpatient Cost to Charge Ratio of 52%","484.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$484.68;102% of Medicaid interim rate","618.75","75","","","Percent of Total Billed Charges","neg_dollar:$618.75","709.50","86","","","Percent of Total Billed Charges","neg_dollar:$709.50","577.50","70","","","Percent of Total Billed Charges","neg_dollar:$577.50","470.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$470.24;103.5% of Medicaid interim rate","825.00","150","","","Percent of Total Billed Charges","neg_dollar:$1275.49;150% of Medicaid interim rate","660.00","80","","","Percent of Total Billed Charges","neg_dollar:$660;Percent of Total Billed Charges","759.00","92","","","Percent of Total Billed Charges","neg_dollar:$759","429.00","52","","","Percent of Total Billed Charges","neg_dollar:$429;100% Medicare Outpatient Cost to Charge Ratio of 52%","429.00","52","","","Percent of Total Billed Charges","neg_dollar:$429;100% Medicare Outpatient Cost to Charge Ratio of 52%","429.00","825.00",""
"MED/SURG SUPPLY LEVEL 43","","","27100043","CDM","270","RC","","Facility","Outpatient","","","2672","2137.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1389.44","52","","","Percent of Total Billed Charges","neg_dollar:$1389.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1389.44","52","","","Percent of Total Billed Charges","neg_dollar:$1389.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","1389.44","52","","","Percent of Total Billed Charges","neg_dollar:$1389.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","1389.44","52","","","Percent of Total Billed Charges","neg_dollar:$1389.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","2297.92","86","","","Percent of Total Billed Charges","neg_dollar:$2297.92","1870.39","70","","","Percent of Total Billed Charges","neg_dollar:$1870.39","1389.44","52","","","Percent of Total Billed Charges","neg_dollar:$1389.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","1569.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$1569.79;102% of Medicaid interim rate","2004.00","75","","","Percent of Total Billed Charges","neg_dollar:$2004","2297.92","86","","","Percent of Total Billed Charges","neg_dollar:$2297.92","1870.39","70","","","Percent of Total Billed Charges","neg_dollar:$1870.39","1523.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$1523.04;103.5% of Medicaid interim rate","2672.00","150","","","Percent of Total Billed Charges","neg_dollar:$4131.04;150% of Medicaid interim rate","2137.60","80","","","Percent of Total Billed Charges","neg_dollar:$2137.60;Percent of Total Billed Charges","2458.24","92","","","Percent of Total Billed Charges","neg_dollar:$2458.24","1389.44","52","","","Percent of Total Billed Charges","neg_dollar:$1389.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","1389.44","52","","","Percent of Total Billed Charges","neg_dollar:$1389.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2672.00",""
"STERILE MED/SURG SUPPLY LEVEL 1","","","27100046","CDM","272","RC","","Facility","Outpatient","","","32","25.60","32.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","16.64","52","","","Percent of Total Billed Charges","neg_dollar:$16.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","32.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","16.64","52","","","Percent of Total Billed Charges","neg_dollar:$16.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.64","52","","","Percent of Total Billed Charges","neg_dollar:$16.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.64","52","","","Percent of Total Billed Charges","neg_dollar:$16.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.52","86","","","Percent of Total Billed Charges","neg_dollar:$27.52","22.40","70","","","Percent of Total Billed Charges","neg_dollar:$22.40","16.64","52","","","Percent of Total Billed Charges","neg_dollar:$16.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","18.79","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.79;102% of Medicaid interim rate","24.00","75","","","Percent of Total Billed Charges","neg_dollar:$24","27.52","86","","","Percent of Total Billed Charges","neg_dollar:$27.52","22.40","70","","","Percent of Total Billed Charges","neg_dollar:$22.40","18.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$18.24;103.5% of Medicaid interim rate","32.00","150","","","Percent of Total Billed Charges","neg_dollar:$49.47;150% of Medicaid interim rate","25.60","80","","","Percent of Total Billed Charges","neg_dollar:$25.60;Percent of Total Billed Charges","29.44","92","","","Percent of Total Billed Charges","neg_dollar:$29.44","16.64","52","","","Percent of Total Billed Charges","neg_dollar:$16.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.64","52","","","Percent of Total Billed Charges","neg_dollar:$16.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","16.00","32.00",""
"STERILE MED/SURG SUPPLY LEVEL 2","","","27100047","CDM","272","RC","","Facility","Outpatient","","","52","41.60","52.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","27.04","52","","","Percent of Total Billed Charges","neg_dollar:$27.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","27.04","52","","","Percent of Total Billed Charges","neg_dollar:$27.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.04","52","","","Percent of Total Billed Charges","neg_dollar:$27.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","27.04","52","","","Percent of Total Billed Charges","neg_dollar:$27.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","44.72","86","","","Percent of Total Billed Charges","neg_dollar:$44.72","36.40","70","","","Percent of Total Billed Charges","neg_dollar:$36.40","27.04","52","","","Percent of Total Billed Charges","neg_dollar:$27.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","30.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.54;102% of Medicaid interim rate","39.00","75","","","Percent of Total Billed Charges","neg_dollar:$39","44.72","86","","","Percent of Total Billed Charges","neg_dollar:$44.72","36.40","70","","","Percent of Total Billed Charges","neg_dollar:$36.40","29.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$29.63;103.5% of Medicaid interim rate","52.00","150","","","Percent of Total Billed Charges","neg_dollar:$80.39;150% of Medicaid interim rate","41.60","80","","","Percent of Total Billed Charges","neg_dollar:$41.60;Percent of Total Billed Charges","47.84","92","","","Percent of Total Billed Charges","neg_dollar:$47.84","27.04","52","","","Percent of Total Billed Charges","neg_dollar:$27.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.04","52","","","Percent of Total Billed Charges","neg_dollar:$27.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","27.00","52.00",""
"STERILE MED/SURG SUPPLY LEVEL 3","","","27100048","CDM","272","RC","","Facility","Outpatient","","","100","80.00","100.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;101% Medicare Outpatient Cost to Charge Ratio of 52%","100.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;102% Medicare Outpatient Cost to Charge Ratio of 52%","86.00","86","","","Percent of Total Billed Charges","neg_dollar:$86","70.00","70","","","Percent of Total Billed Charges","neg_dollar:$70","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;105% Medicare Outpatient Cost to Charge Ratio of 52%","58.74","56.99","","","Percent of Total Billed Charges","neg_dollar:$58.74;102% of Medicaid interim rate","75.00","75","","","Percent of Total Billed Charges","neg_dollar:$75","86.00","86","","","Percent of Total Billed Charges","neg_dollar:$86","70.00","70","","","Percent of Total Billed Charges","neg_dollar:$70","56.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.99;103.5% of Medicaid interim rate","100.00","150","","","Percent of Total Billed Charges","neg_dollar:$154.60;150% of Medicaid interim rate","80.00","80","","","Percent of Total Billed Charges","neg_dollar:$80;Percent of Total Billed Charges","92.00","92","","","Percent of Total Billed Charges","neg_dollar:$92","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;100% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","52","","","Percent of Total Billed Charges","neg_dollar:$52;100% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","100.00",""
"STERILE MED/SURG SUPPLY LEVEL 4","","","27100049","CDM","272","RC","","Facility","Outpatient","","","167","133.60","167.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","86.84","52","","","Percent of Total Billed Charges","neg_dollar:$86.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","167.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","86.84","52","","","Percent of Total Billed Charges","neg_dollar:$86.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","86.84","52","","","Percent of Total Billed Charges","neg_dollar:$86.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","86.84","52","","","Percent of Total Billed Charges","neg_dollar:$86.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","143.62","86","","","Percent of Total Billed Charges","neg_dollar:$143.62","116.89","70","","","Percent of Total Billed Charges","neg_dollar:$116.89","86.84","52","","","Percent of Total Billed Charges","neg_dollar:$86.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","98.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$98.11;102% of Medicaid interim rate","125.25","75","","","Percent of Total Billed Charges","neg_dollar:$125.25","143.62","86","","","Percent of Total Billed Charges","neg_dollar:$143.62","116.89","70","","","Percent of Total Billed Charges","neg_dollar:$116.89","95.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$95.19;103.5% of Medicaid interim rate","167.00","150","","","Percent of Total Billed Charges","neg_dollar:$258.19;150% of Medicaid interim rate","133.60","80","","","Percent of Total Billed Charges","neg_dollar:$133.60;Percent of Total Billed Charges","153.64","92","","","Percent of Total Billed Charges","neg_dollar:$153.64","86.84","52","","","Percent of Total Billed Charges","neg_dollar:$86.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","86.84","52","","","Percent of Total Billed Charges","neg_dollar:$86.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","86.00","167.00",""
"STERILE MED/SURG SUPPLY LEVEL 5","","","27100050","CDM","272","RC","","Facility","Outpatient","","","259","207.20","259.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;101% Medicare Outpatient Cost to Charge Ratio of 52%","259.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;102% Medicare Outpatient Cost to Charge Ratio of 52%","222.74","86","","","Percent of Total Billed Charges","neg_dollar:$222.74","181.29","70","","","Percent of Total Billed Charges","neg_dollar:$181.29","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;105% Medicare Outpatient Cost to Charge Ratio of 52%","152.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$152.16;102% of Medicaid interim rate","194.25","75","","","Percent of Total Billed Charges","neg_dollar:$194.25","222.74","86","","","Percent of Total Billed Charges","neg_dollar:$222.74","181.29","70","","","Percent of Total Billed Charges","neg_dollar:$181.29","147.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$147.63;103.5% of Medicaid interim rate","259.00","150","","","Percent of Total Billed Charges","neg_dollar:$400.42;150% of Medicaid interim rate","207.20","80","","","Percent of Total Billed Charges","neg_dollar:$207.20;Percent of Total Billed Charges","238.28","92","","","Percent of Total Billed Charges","neg_dollar:$238.28","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","134.68","52","","","Percent of Total Billed Charges","neg_dollar:$134.68;100% Medicare Outpatient Cost to Charge Ratio of 52%","134.00","259.00",""
"STERILE MED/SURG SUPPLY LEVEL 6","","","27100051","CDM","272","RC","","Facility","Outpatient","","","318","254.40","318.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","318.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","273.48","86","","","Percent of Total Billed Charges","neg_dollar:$273.48","222.60","70","","","Percent of Total Billed Charges","neg_dollar:$222.60","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","186.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$186.82;102% of Medicaid interim rate","238.50","75","","","Percent of Total Billed Charges","neg_dollar:$238.50","273.48","86","","","Percent of Total Billed Charges","neg_dollar:$273.48","222.60","70","","","Percent of Total Billed Charges","neg_dollar:$222.60","181.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$181.26;103.5% of Medicaid interim rate","318.00","150","","","Percent of Total Billed Charges","neg_dollar:$491.64;150% of Medicaid interim rate","254.40","80","","","Percent of Total Billed Charges","neg_dollar:$254.40;Percent of Total Billed Charges","292.56","92","","","Percent of Total Billed Charges","neg_dollar:$292.56","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","165.00","318.00",""
"STERILE MED/SURG SUPPLY LEVEL 7","","","27100052","CDM","272","RC","","Facility","Outpatient","","","210","168.00","210.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","109.20","52","","","Percent of Total Billed Charges","neg_dollar:$109.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","210.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","109.20","52","","","Percent of Total Billed Charges","neg_dollar:$109.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","109.20","52","","","Percent of Total Billed Charges","neg_dollar:$109.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","109.20","52","","","Percent of Total Billed Charges","neg_dollar:$109.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","180.60","86","","","Percent of Total Billed Charges","neg_dollar:$180.60","147.00","70","","","Percent of Total Billed Charges","neg_dollar:$147","109.20","52","","","Percent of Total Billed Charges","neg_dollar:$109.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","123.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$123.37;102% of Medicaid interim rate","157.50","75","","","Percent of Total Billed Charges","neg_dollar:$157.50","180.60","86","","","Percent of Total Billed Charges","neg_dollar:$180.60","147.00","70","","","Percent of Total Billed Charges","neg_dollar:$147","119.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$119.69;103.5% of Medicaid interim rate","210.00","150","","","Percent of Total Billed Charges","neg_dollar:$324.67;150% of Medicaid interim rate","168.00","80","","","Percent of Total Billed Charges","neg_dollar:$168;Percent of Total Billed Charges","193.20","92","","","Percent of Total Billed Charges","neg_dollar:$193.20","109.20","52","","","Percent of Total Billed Charges","neg_dollar:$109.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","109.20","52","","","Percent of Total Billed Charges","neg_dollar:$109.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","109.00","210.00",""
"STERILE MED/SURG SUPPLY LEVEL 8","","","27100053","CDM","272","RC","","Facility","Outpatient","","","307","245.60","307.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","159.64","52","","","Percent of Total Billed Charges","neg_dollar:$159.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","307.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","159.64","52","","","Percent of Total Billed Charges","neg_dollar:$159.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","159.64","52","","","Percent of Total Billed Charges","neg_dollar:$159.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","159.64","52","","","Percent of Total Billed Charges","neg_dollar:$159.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","264.02","86","","","Percent of Total Billed Charges","neg_dollar:$264.02","214.89","70","","","Percent of Total Billed Charges","neg_dollar:$214.89","159.64","52","","","Percent of Total Billed Charges","neg_dollar:$159.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","180.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$180.36;102% of Medicaid interim rate","230.25","75","","","Percent of Total Billed Charges","neg_dollar:$230.25","264.02","86","","","Percent of Total Billed Charges","neg_dollar:$264.02","214.89","70","","","Percent of Total Billed Charges","neg_dollar:$214.89","174.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$174.98;103.5% of Medicaid interim rate","307.00","150","","","Percent of Total Billed Charges","neg_dollar:$474.63;150% of Medicaid interim rate","245.60","80","","","Percent of Total Billed Charges","neg_dollar:$245.60;Percent of Total Billed Charges","282.44","92","","","Percent of Total Billed Charges","neg_dollar:$282.44","159.64","52","","","Percent of Total Billed Charges","neg_dollar:$159.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","159.64","52","","","Percent of Total Billed Charges","neg_dollar:$159.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","159.00","307.00",""
"STERILE MED/SURG SUPPLY LEVEL 9","","","27100054","CDM","272","RC","","Facility","Outpatient","","","350","280.00","350.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","182.00","52","","","Percent of Total Billed Charges","neg_dollar:$182;101% Medicare Outpatient Cost to Charge Ratio of 52%","350.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","182.00","52","","","Percent of Total Billed Charges","neg_dollar:$182;102% Medicare Outpatient Cost to Charge Ratio of 52%","182.00","52","","","Percent of Total Billed Charges","neg_dollar:$182;102% Medicare Outpatient Cost to Charge Ratio of 52%","182.00","52","","","Percent of Total Billed Charges","neg_dollar:$182;102% Medicare Outpatient Cost to Charge Ratio of 52%","301.00","86","","","Percent of Total Billed Charges","neg_dollar:$301","244.99","70","","","Percent of Total Billed Charges","neg_dollar:$244.99","182.00","52","","","Percent of Total Billed Charges","neg_dollar:$182;105% Medicare Outpatient Cost to Charge Ratio of 52%","205.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$205.62;102% of Medicaid interim rate","262.50","75","","","Percent of Total Billed Charges","neg_dollar:$262.50","301.00","86","","","Percent of Total Billed Charges","neg_dollar:$301","244.99","70","","","Percent of Total Billed Charges","neg_dollar:$244.99","199.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$199.49;103.5% of Medicaid interim rate","350.00","150","","","Percent of Total Billed Charges","neg_dollar:$541.11;150% of Medicaid interim rate","280.00","80","","","Percent of Total Billed Charges","neg_dollar:$280;Percent of Total Billed Charges","322.00","92","","","Percent of Total Billed Charges","neg_dollar:$322","182.00","52","","","Percent of Total Billed Charges","neg_dollar:$182;100% Medicare Outpatient Cost to Charge Ratio of 52%","182.00","52","","","Percent of Total Billed Charges","neg_dollar:$182;100% Medicare Outpatient Cost to Charge Ratio of 52%","182.00","350.00",""
"STERILE MED/SURG SUPPLY LEVEL 10","","","27100055","CDM","272","RC","","Facility","Outpatient","","","391","312.80","391.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","391.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","336.26","86","","","Percent of Total Billed Charges","neg_dollar:$336.26","273.70","70","","","Percent of Total Billed Charges","neg_dollar:$273.70","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","229.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$229.71;102% of Medicaid interim rate","293.25","75","","","Percent of Total Billed Charges","neg_dollar:$293.25","336.26","86","","","Percent of Total Billed Charges","neg_dollar:$336.26","273.70","70","","","Percent of Total Billed Charges","neg_dollar:$273.70","222.86","56.99","","","Percent of Total Billed Charges","neg_dollar:$222.86;103.5% of Medicaid interim rate","391.00","150","","","Percent of Total Billed Charges","neg_dollar:$604.50;150% of Medicaid interim rate","312.80","80","","","Percent of Total Billed Charges","neg_dollar:$312.80;Percent of Total Billed Charges","359.72","92","","","Percent of Total Billed Charges","neg_dollar:$359.72","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","203.32","52","","","Percent of Total Billed Charges","neg_dollar:$203.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","203.00","391.00",""
"STERILE MED/SURG SUPPLY LEVEL 11","","","27100056","CDM","272","RC","","Facility","Outpatient","","","431","344.80","431.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","431.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","370.65","86","","","Percent of Total Billed Charges","neg_dollar:$370.65","301.70","70","","","Percent of Total Billed Charges","neg_dollar:$301.70","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","253.21","56.99","","","Percent of Total Billed Charges","neg_dollar:$253.21;102% of Medicaid interim rate","323.25","75","","","Percent of Total Billed Charges","neg_dollar:$323.25","370.65","86","","","Percent of Total Billed Charges","neg_dollar:$370.65","301.70","70","","","Percent of Total Billed Charges","neg_dollar:$301.70","245.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$245.67;103.5% of Medicaid interim rate","431.00","150","","","Percent of Total Billed Charges","neg_dollar:$666.34;150% of Medicaid interim rate","344.80","80","","","Percent of Total Billed Charges","neg_dollar:$344.80;Percent of Total Billed Charges","396.52","92","","","Percent of Total Billed Charges","neg_dollar:$396.52","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","224.12","52","","","Percent of Total Billed Charges","neg_dollar:$224.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","224.00","431.00",""
"STERILE MED/SURG SUPPLY LEVEL 12","","","27100057","CDM","272","RC","","Facility","Outpatient","","","502","401.60","502.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","261.04","52","","","Percent of Total Billed Charges","neg_dollar:$261.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","502.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","261.04","52","","","Percent of Total Billed Charges","neg_dollar:$261.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","261.04","52","","","Percent of Total Billed Charges","neg_dollar:$261.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","261.04","52","","","Percent of Total Billed Charges","neg_dollar:$261.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","431.71","86","","","Percent of Total Billed Charges","neg_dollar:$431.71","351.40","70","","","Percent of Total Billed Charges","neg_dollar:$351.40","261.04","52","","","Percent of Total Billed Charges","neg_dollar:$261.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","294.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$294.92;102% of Medicaid interim rate","376.50","75","","","Percent of Total Billed Charges","neg_dollar:$376.50","431.71","86","","","Percent of Total Billed Charges","neg_dollar:$431.71","351.40","70","","","Percent of Total Billed Charges","neg_dollar:$351.40","286.14","56.99","","","Percent of Total Billed Charges","neg_dollar:$286.14;103.5% of Medicaid interim rate","502.00","150","","","Percent of Total Billed Charges","neg_dollar:$776.11;150% of Medicaid interim rate","401.60","80","","","Percent of Total Billed Charges","neg_dollar:$401.60;Percent of Total Billed Charges","461.84","92","","","Percent of Total Billed Charges","neg_dollar:$461.84","261.04","52","","","Percent of Total Billed Charges","neg_dollar:$261.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","261.04","52","","","Percent of Total Billed Charges","neg_dollar:$261.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","261.00","502.00",""
"STERILE MED/SURG SUPPLY LEVEL 13","","","27100058","CDM","272","RC","","Facility","Outpatient","","","590","472.00","590.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","306.80","52","","","Percent of Total Billed Charges","neg_dollar:$306.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","590.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","306.80","52","","","Percent of Total Billed Charges","neg_dollar:$306.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","306.80","52","","","Percent of Total Billed Charges","neg_dollar:$306.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","306.80","52","","","Percent of Total Billed Charges","neg_dollar:$306.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","507.40","86","","","Percent of Total Billed Charges","neg_dollar:$507.40","413.00","70","","","Percent of Total Billed Charges","neg_dollar:$413","306.80","52","","","Percent of Total Billed Charges","neg_dollar:$306.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","346.62","56.99","","","Percent of Total Billed Charges","neg_dollar:$346.62;102% of Medicaid interim rate","442.50","75","","","Percent of Total Billed Charges","neg_dollar:$442.50","507.40","86","","","Percent of Total Billed Charges","neg_dollar:$507.40","413.00","70","","","Percent of Total Billed Charges","neg_dollar:$413","336.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$336.29;103.5% of Medicaid interim rate","590.00","150","","","Percent of Total Billed Charges","neg_dollar:$912.16;150% of Medicaid interim rate","472.00","80","","","Percent of Total Billed Charges","neg_dollar:$472;Percent of Total Billed Charges","542.80","92","","","Percent of Total Billed Charges","neg_dollar:$542.80","306.80","52","","","Percent of Total Billed Charges","neg_dollar:$306.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","306.80","52","","","Percent of Total Billed Charges","neg_dollar:$306.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","306.00","590.00",""
"STERILE MED/SURG SUPPLY LEVEL 14","","","27100059","CDM","272","RC","","Facility","Outpatient","","","598","478.40","598.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","310.96","52","","","Percent of Total Billed Charges","neg_dollar:$310.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","598.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","310.96","52","","","Percent of Total Billed Charges","neg_dollar:$310.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","310.96","52","","","Percent of Total Billed Charges","neg_dollar:$310.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","310.96","52","","","Percent of Total Billed Charges","neg_dollar:$310.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","514.28","86","","","Percent of Total Billed Charges","neg_dollar:$514.28","418.59","70","","","Percent of Total Billed Charges","neg_dollar:$418.59","310.96","52","","","Percent of Total Billed Charges","neg_dollar:$310.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","351.32","56.99","","","Percent of Total Billed Charges","neg_dollar:$351.32;102% of Medicaid interim rate","448.50","75","","","Percent of Total Billed Charges","neg_dollar:$448.50","514.28","86","","","Percent of Total Billed Charges","neg_dollar:$514.28","418.59","70","","","Percent of Total Billed Charges","neg_dollar:$418.59","340.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$340.85;103.5% of Medicaid interim rate","598.00","150","","","Percent of Total Billed Charges","neg_dollar:$924.53;150% of Medicaid interim rate","478.40","80","","","Percent of Total Billed Charges","neg_dollar:$478.40;Percent of Total Billed Charges","550.16","92","","","Percent of Total Billed Charges","neg_dollar:$550.16","310.96","52","","","Percent of Total Billed Charges","neg_dollar:$310.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","310.96","52","","","Percent of Total Billed Charges","neg_dollar:$310.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","310.00","598.00",""
"STERILE MED/SURG SUPPLY LEVEL 15","","","27100060","CDM","272","RC","","Facility","Outpatient","","","704","563.20","704.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","704.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","605.43","86","","","Percent of Total Billed Charges","neg_dollar:$605.43","492.79","70","","","Percent of Total Billed Charges","neg_dollar:$492.79","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","413.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$413.59;102% of Medicaid interim rate","528.00","75","","","Percent of Total Billed Charges","neg_dollar:$528","605.43","86","","","Percent of Total Billed Charges","neg_dollar:$605.43","492.79","70","","","Percent of Total Billed Charges","neg_dollar:$492.79","401.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$401.28;103.5% of Medicaid interim rate","704.00","150","","","Percent of Total Billed Charges","neg_dollar:$1088.41;150% of Medicaid interim rate","563.20","80","","","Percent of Total Billed Charges","neg_dollar:$563.20;Percent of Total Billed Charges","647.68","92","","","Percent of Total Billed Charges","neg_dollar:$647.68","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.08","52","","","Percent of Total Billed Charges","neg_dollar:$366.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.00","704.00",""
"STERILE MED/SURG SUPPLY LEVEL 16","","","27100061","CDM","272","RC","","Facility","Outpatient","","","885","708.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","761.10","86","","","Percent of Total Billed Charges","neg_dollar:$761.10","619.50","70","","","Percent of Total Billed Charges","neg_dollar:$619.50","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","519.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$519.93;102% of Medicaid interim rate","663.75","75","","","Percent of Total Billed Charges","neg_dollar:$663.75","761.10","86","","","Percent of Total Billed Charges","neg_dollar:$761.10","619.50","70","","","Percent of Total Billed Charges","neg_dollar:$619.50","504.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$504.44;103.5% of Medicaid interim rate","885.00","150","","","Percent of Total Billed Charges","neg_dollar:$1368.25;150% of Medicaid interim rate","708.00","80","","","Percent of Total Billed Charges","neg_dollar:$708;Percent of Total Billed Charges","814.20","92","","","Percent of Total Billed Charges","neg_dollar:$814.20","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","460.20","52","","","Percent of Total Billed Charges","neg_dollar:$460.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","460.00","885.00",""
"STERILE MED/SURG SUPPLY LEVEL 17","","","27100062","CDM","272","RC","","Facility","Outpatient","","","973","778.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","505.96","52","","","Percent of Total Billed Charges","neg_dollar:$505.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","505.96","52","","","Percent of Total Billed Charges","neg_dollar:$505.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","505.96","52","","","Percent of Total Billed Charges","neg_dollar:$505.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","505.96","52","","","Percent of Total Billed Charges","neg_dollar:$505.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","836.78","86","","","Percent of Total Billed Charges","neg_dollar:$836.78","681.09","70","","","Percent of Total Billed Charges","neg_dollar:$681.09","505.96","52","","","Percent of Total Billed Charges","neg_dollar:$505.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","571.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$571.63;102% of Medicaid interim rate","729.75","75","","","Percent of Total Billed Charges","neg_dollar:$729.75","836.78","86","","","Percent of Total Billed Charges","neg_dollar:$836.78","681.09","70","","","Percent of Total Billed Charges","neg_dollar:$681.09","554.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$554.60;103.5% of Medicaid interim rate","973.00","150","","","Percent of Total Billed Charges","neg_dollar:$1504.30;150% of Medicaid interim rate","778.40","80","","","Percent of Total Billed Charges","neg_dollar:$778.40;Percent of Total Billed Charges","895.16","92","","","Percent of Total Billed Charges","neg_dollar:$895.16","505.96","52","","","Percent of Total Billed Charges","neg_dollar:$505.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","505.96","52","","","Percent of Total Billed Charges","neg_dollar:$505.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","505.00","973.00",""
"STERILE MED/SURG SUPPLY LEVEL 18","","","27100063","CDM","272","RC","","Facility","Outpatient","","","1055","844.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","907.30","86","","","Percent of Total Billed Charges","neg_dollar:$907.30","738.50","70","","","Percent of Total Billed Charges","neg_dollar:$738.50","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","619.81","56.99","","","Percent of Total Billed Charges","neg_dollar:$619.81;102% of Medicaid interim rate","791.25","75","","","Percent of Total Billed Charges","neg_dollar:$791.25","907.30","86","","","Percent of Total Billed Charges","neg_dollar:$907.30","738.50","70","","","Percent of Total Billed Charges","neg_dollar:$738.50","601.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$601.34;103.5% of Medicaid interim rate","1055.00","150","","","Percent of Total Billed Charges","neg_dollar:$1631.08;150% of Medicaid interim rate","844.00","80","","","Percent of Total Billed Charges","neg_dollar:$844;Percent of Total Billed Charges","970.60","92","","","Percent of Total Billed Charges","neg_dollar:$970.60","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","548.60","52","","","Percent of Total Billed Charges","neg_dollar:$548.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","548.00","1055.00",""
"STERILE MED/SURG SUPPLY LEVEL 19","","","27100064","CDM","272","RC","","Facility","Outpatient","","","1136","908.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","590.72","52","","","Percent of Total Billed Charges","neg_dollar:$590.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","590.72","52","","","Percent of Total Billed Charges","neg_dollar:$590.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","590.72","52","","","Percent of Total Billed Charges","neg_dollar:$590.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","590.72","52","","","Percent of Total Billed Charges","neg_dollar:$590.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","976.96","86","","","Percent of Total Billed Charges","neg_dollar:$976.96","795.19","70","","","Percent of Total Billed Charges","neg_dollar:$795.19","590.72","52","","","Percent of Total Billed Charges","neg_dollar:$590.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","667.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$667.39;102% of Medicaid interim rate","852.00","75","","","Percent of Total Billed Charges","neg_dollar:$852","976.96","86","","","Percent of Total Billed Charges","neg_dollar:$976.96","795.19","70","","","Percent of Total Billed Charges","neg_dollar:$795.19","647.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$647.52;103.5% of Medicaid interim rate","1136.00","150","","","Percent of Total Billed Charges","neg_dollar:$1756.31;150% of Medicaid interim rate","908.80","80","","","Percent of Total Billed Charges","neg_dollar:$908.80;Percent of Total Billed Charges","1045.12","92","","","Percent of Total Billed Charges","neg_dollar:$1045.12","590.72","52","","","Percent of Total Billed Charges","neg_dollar:$590.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","590.72","52","","","Percent of Total Billed Charges","neg_dollar:$590.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","590.00","1136.00",""
"STERILE MED/SURG SUPPLY LEVEL 20","","","27100065","CDM","272","RC","","Facility","Outpatient","","","1211","968.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1041.46","86","","","Percent of Total Billed Charges","neg_dollar:$1041.46","847.69","70","","","Percent of Total Billed Charges","neg_dollar:$847.69","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","711.46","56.99","","","Percent of Total Billed Charges","neg_dollar:$711.46;102% of Medicaid interim rate","908.25","75","","","Percent of Total Billed Charges","neg_dollar:$908.25","1041.46","86","","","Percent of Total Billed Charges","neg_dollar:$1041.46","847.69","70","","","Percent of Total Billed Charges","neg_dollar:$847.69","690.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$690.27;103.5% of Medicaid interim rate","1211.00","150","","","Percent of Total Billed Charges","neg_dollar:$1872.26;150% of Medicaid interim rate","968.80","80","","","Percent of Total Billed Charges","neg_dollar:$968.80;Percent of Total Billed Charges","1114.12","92","","","Percent of Total Billed Charges","neg_dollar:$1114.12","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","629.72","52","","","Percent of Total Billed Charges","neg_dollar:$629.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","629.00","1211.00",""
"STERILE MED/SURG SUPPLY LEVEL 21","","","27100066","CDM","272","RC","","Facility","Outpatient","","","1285","1028.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","1105.10","86","","","Percent of Total Billed Charges","neg_dollar:$1105.10","899.49","70","","","Percent of Total Billed Charges","neg_dollar:$899.49","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","754.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$754.93;102% of Medicaid interim rate","963.75","75","","","Percent of Total Billed Charges","neg_dollar:$963.75","1105.10","86","","","Percent of Total Billed Charges","neg_dollar:$1105.10","899.49","70","","","Percent of Total Billed Charges","neg_dollar:$899.49","732.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$732.44;103.5% of Medicaid interim rate","1285.00","150","","","Percent of Total Billed Charges","neg_dollar:$1986.67;150% of Medicaid interim rate","1028.00","80","","","Percent of Total Billed Charges","neg_dollar:$1028;Percent of Total Billed Charges","1182.20","92","","","Percent of Total Billed Charges","neg_dollar:$1182.20","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","668.20","52","","","Percent of Total Billed Charges","neg_dollar:$668.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","668.00","1285.00",""
"STERILE MED/SURG SUPPLY LEVEL 22","","","27100067","CDM","272","RC","","Facility","Outpatient","","","1394","1115.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","724.88","52","","","Percent of Total Billed Charges","neg_dollar:$724.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","724.88","52","","","Percent of Total Billed Charges","neg_dollar:$724.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","724.88","52","","","Percent of Total Billed Charges","neg_dollar:$724.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","724.88","52","","","Percent of Total Billed Charges","neg_dollar:$724.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","1198.84","86","","","Percent of Total Billed Charges","neg_dollar:$1198.84","975.80","70","","","Percent of Total Billed Charges","neg_dollar:$975.80","724.88","52","","","Percent of Total Billed Charges","neg_dollar:$724.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","818.97","56.99","","","Percent of Total Billed Charges","neg_dollar:$818.97;102% of Medicaid interim rate","1045.50","75","","","Percent of Total Billed Charges","neg_dollar:$1045.50","1198.84","86","","","Percent of Total Billed Charges","neg_dollar:$1198.84","975.80","70","","","Percent of Total Billed Charges","neg_dollar:$975.80","794.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$794.57;103.5% of Medicaid interim rate","1394.00","150","","","Percent of Total Billed Charges","neg_dollar:$2155.19;150% of Medicaid interim rate","1115.20","80","","","Percent of Total Billed Charges","neg_dollar:$1115.20;Percent of Total Billed Charges","1282.48","92","","","Percent of Total Billed Charges","neg_dollar:$1282.48","724.88","52","","","Percent of Total Billed Charges","neg_dollar:$724.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","724.88","52","","","Percent of Total Billed Charges","neg_dollar:$724.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","724.00","1394.00",""
"STERILE MED/SURG SUPPLY LEVEL 23","","","27100068","CDM","272","RC","","Facility","Outpatient","","","1420","1136.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","738.40","52","","","Percent of Total Billed Charges","neg_dollar:$738.40;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","738.40","52","","","Percent of Total Billed Charges","neg_dollar:$738.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","738.40","52","","","Percent of Total Billed Charges","neg_dollar:$738.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","738.40","52","","","Percent of Total Billed Charges","neg_dollar:$738.40;102% Medicare Outpatient Cost to Charge Ratio of 52%","1221.20","86","","","Percent of Total Billed Charges","neg_dollar:$1221.20","993.99","70","","","Percent of Total Billed Charges","neg_dollar:$993.99","738.40","52","","","Percent of Total Billed Charges","neg_dollar:$738.40;105% Medicare Outpatient Cost to Charge Ratio of 52%","834.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$834.24;102% of Medicaid interim rate","1065.00","75","","","Percent of Total Billed Charges","neg_dollar:$1065","1221.20","86","","","Percent of Total Billed Charges","neg_dollar:$1221.20","993.99","70","","","Percent of Total Billed Charges","neg_dollar:$993.99","809.40","56.99","","","Percent of Total Billed Charges","neg_dollar:$809.40;103.5% of Medicaid interim rate","1420.00","150","","","Percent of Total Billed Charges","neg_dollar:$2195.39;150% of Medicaid interim rate","1136.00","80","","","Percent of Total Billed Charges","neg_dollar:$1136;Percent of Total Billed Charges","1306.40","92","","","Percent of Total Billed Charges","neg_dollar:$1306.40","738.40","52","","","Percent of Total Billed Charges","neg_dollar:$738.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","738.40","52","","","Percent of Total Billed Charges","neg_dollar:$738.40;100% Medicare Outpatient Cost to Charge Ratio of 52%","738.00","1420.00",""
"STERILE MED/SURG SUPPLY LEVEL 24","","","27100069","CDM","272","RC","","Facility","Outpatient","","","1536","1228.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;102% Medicare Outpatient Cost to Charge Ratio of 52%","1320.96","86","","","Percent of Total Billed Charges","neg_dollar:$1320.96","1075.19","70","","","Percent of Total Billed Charges","neg_dollar:$1075.19","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;105% Medicare Outpatient Cost to Charge Ratio of 52%","902.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$902.39;102% of Medicaid interim rate","1152.00","75","","","Percent of Total Billed Charges","neg_dollar:$1152","1320.96","86","","","Percent of Total Billed Charges","neg_dollar:$1320.96","1075.19","70","","","Percent of Total Billed Charges","neg_dollar:$1075.19","875.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$875.52;103.5% of Medicaid interim rate","1536.00","150","","","Percent of Total Billed Charges","neg_dollar:$2374.73;150% of Medicaid interim rate","1228.80","80","","","Percent of Total Billed Charges","neg_dollar:$1228.80;Percent of Total Billed Charges","1413.12","92","","","Percent of Total Billed Charges","neg_dollar:$1413.12","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","798.72","52","","","Percent of Total Billed Charges","neg_dollar:$798.72;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1536.00",""
"STERILE MED/SURG SUPPLY LEVEL 25","","","27100070","CDM","272","RC","","Facility","Outpatient","","","1542","1233.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","801.84","52","","","Percent of Total Billed Charges","neg_dollar:$801.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","801.84","52","","","Percent of Total Billed Charges","neg_dollar:$801.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","801.84","52","","","Percent of Total Billed Charges","neg_dollar:$801.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","801.84","52","","","Percent of Total Billed Charges","neg_dollar:$801.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","1326.12","86","","","Percent of Total Billed Charges","neg_dollar:$1326.12","1079.39","70","","","Percent of Total Billed Charges","neg_dollar:$1079.39","801.84","52","","","Percent of Total Billed Charges","neg_dollar:$801.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","905.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$905.92;102% of Medicaid interim rate","1156.50","75","","","Percent of Total Billed Charges","neg_dollar:$1156.50","1326.12","86","","","Percent of Total Billed Charges","neg_dollar:$1326.12","1079.39","70","","","Percent of Total Billed Charges","neg_dollar:$1079.39","878.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$878.93;103.5% of Medicaid interim rate","1542.00","150","","","Percent of Total Billed Charges","neg_dollar:$2384;150% of Medicaid interim rate","1233.60","80","","","Percent of Total Billed Charges","neg_dollar:$1233.60;Percent of Total Billed Charges","1418.64","92","","","Percent of Total Billed Charges","neg_dollar:$1418.64","801.84","52","","","Percent of Total Billed Charges","neg_dollar:$801.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","801.84","52","","","Percent of Total Billed Charges","neg_dollar:$801.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1542.00",""
"STERILE MED/SURG SUPPLY LEVEL 26","","","27100071","CDM","272","RC","","Facility","Outpatient","","","1598","1278.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1374.28","86","","","Percent of Total Billed Charges","neg_dollar:$1374.28","1118.60","70","","","Percent of Total Billed Charges","neg_dollar:$1118.60","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","938.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$938.82;102% of Medicaid interim rate","1198.50","75","","","Percent of Total Billed Charges","neg_dollar:$1198.50","1374.28","86","","","Percent of Total Billed Charges","neg_dollar:$1374.28","1118.60","70","","","Percent of Total Billed Charges","neg_dollar:$1118.60","910.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$910.85;103.5% of Medicaid interim rate","1598.00","150","","","Percent of Total Billed Charges","neg_dollar:$2470.58;150% of Medicaid interim rate","1278.40","80","","","Percent of Total Billed Charges","neg_dollar:$1278.40;Percent of Total Billed Charges","1470.16","92","","","Percent of Total Billed Charges","neg_dollar:$1470.16","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","830.96","52","","","Percent of Total Billed Charges","neg_dollar:$830.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1598.00",""
"STERILE MED/SURG SUPPLY LEVEL 27","","","27100072","CDM","272","RC","","Facility","Outpatient","","","1706","1364.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","887.12","52","","","Percent of Total Billed Charges","neg_dollar:$887.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","887.12","52","","","Percent of Total Billed Charges","neg_dollar:$887.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","887.12","52","","","Percent of Total Billed Charges","neg_dollar:$887.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","887.12","52","","","Percent of Total Billed Charges","neg_dollar:$887.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","1467.16","86","","","Percent of Total Billed Charges","neg_dollar:$1467.16","1194.19","70","","","Percent of Total Billed Charges","neg_dollar:$1194.19","887.12","52","","","Percent of Total Billed Charges","neg_dollar:$887.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","1002.27","56.99","","","Percent of Total Billed Charges","neg_dollar:$1002.27;102% of Medicaid interim rate","1279.50","75","","","Percent of Total Billed Charges","neg_dollar:$1279.50","1467.16","86","","","Percent of Total Billed Charges","neg_dollar:$1467.16","1194.19","70","","","Percent of Total Billed Charges","neg_dollar:$1194.19","972.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$972.42;103.5% of Medicaid interim rate","1706.00","150","","","Percent of Total Billed Charges","neg_dollar:$2637.56;150% of Medicaid interim rate","1364.80","80","","","Percent of Total Billed Charges","neg_dollar:$1364.80;Percent of Total Billed Charges","1569.52","92","","","Percent of Total Billed Charges","neg_dollar:$1569.52","887.12","52","","","Percent of Total Billed Charges","neg_dollar:$887.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","887.12","52","","","Percent of Total Billed Charges","neg_dollar:$887.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1706.00",""
"STERILE MED/SURG SUPPLY LEVEL 28","","","27100073","CDM","272","RC","","Facility","Outpatient","","","1848","1478.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1589.28","86","","","Percent of Total Billed Charges","neg_dollar:$1589.28","1293.60","70","","","Percent of Total Billed Charges","neg_dollar:$1293.60","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","1085.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$1085.69;102% of Medicaid interim rate","1386.00","75","","","Percent of Total Billed Charges","neg_dollar:$1386","1589.28","86","","","Percent of Total Billed Charges","neg_dollar:$1589.28","1293.60","70","","","Percent of Total Billed Charges","neg_dollar:$1293.60","1053.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$1053.36;103.5% of Medicaid interim rate","1848.00","150","","","Percent of Total Billed Charges","neg_dollar:$2857.10;150% of Medicaid interim rate","1478.40","80","","","Percent of Total Billed Charges","neg_dollar:$1478.40;Percent of Total Billed Charges","1700.16","92","","","Percent of Total Billed Charges","neg_dollar:$1700.16","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1848.00",""
"STERILE MED/SURG SUPPLY LEVEL 29","","","27100074","CDM","272","RC","","Facility","Outpatient","","","1848","1478.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1589.28","86","","","Percent of Total Billed Charges","neg_dollar:$1589.28","1293.60","70","","","Percent of Total Billed Charges","neg_dollar:$1293.60","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","1085.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$1085.69;102% of Medicaid interim rate","1386.00","75","","","Percent of Total Billed Charges","neg_dollar:$1386","1589.28","86","","","Percent of Total Billed Charges","neg_dollar:$1589.28","1293.60","70","","","Percent of Total Billed Charges","neg_dollar:$1293.60","1053.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$1053.36;103.5% of Medicaid interim rate","1848.00","150","","","Percent of Total Billed Charges","neg_dollar:$2857.10;150% of Medicaid interim rate","1478.40","80","","","Percent of Total Billed Charges","neg_dollar:$1478.40;Percent of Total Billed Charges","1700.16","92","","","Percent of Total Billed Charges","neg_dollar:$1700.16","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1848.00",""
"STERILE MED/SURG SUPPLY LEVEL 30","","","27100075","CDM","272","RC","","Facility","Outpatient","","","1848","1478.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","1589.28","86","","","Percent of Total Billed Charges","neg_dollar:$1589.28","1293.60","70","","","Percent of Total Billed Charges","neg_dollar:$1293.60","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","1085.69","56.99","","","Percent of Total Billed Charges","neg_dollar:$1085.69;102% of Medicaid interim rate","1386.00","75","","","Percent of Total Billed Charges","neg_dollar:$1386","1589.28","86","","","Percent of Total Billed Charges","neg_dollar:$1589.28","1293.60","70","","","Percent of Total Billed Charges","neg_dollar:$1293.60","1053.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$1053.36;103.5% of Medicaid interim rate","1848.00","150","","","Percent of Total Billed Charges","neg_dollar:$2857.10;150% of Medicaid interim rate","1478.40","80","","","Percent of Total Billed Charges","neg_dollar:$1478.40;Percent of Total Billed Charges","1700.16","92","","","Percent of Total Billed Charges","neg_dollar:$1700.16","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","960.96","52","","","Percent of Total Billed Charges","neg_dollar:$960.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1848.00",""
"STERILE MED/SURG SUPPLY LEVEL 31","","","27100076","CDM","272","RC","","Facility","Outpatient","","","1991","1592.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1035.32","52","","","Percent of Total Billed Charges","neg_dollar:$1035.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1035.32","52","","","Percent of Total Billed Charges","neg_dollar:$1035.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1035.32","52","","","Percent of Total Billed Charges","neg_dollar:$1035.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1035.32","52","","","Percent of Total Billed Charges","neg_dollar:$1035.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","1712.26","86","","","Percent of Total Billed Charges","neg_dollar:$1712.26","1393.69","70","","","Percent of Total Billed Charges","neg_dollar:$1393.69","1035.32","52","","","Percent of Total Billed Charges","neg_dollar:$1035.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","1169.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$1169.71;102% of Medicaid interim rate","1493.25","75","","","Percent of Total Billed Charges","neg_dollar:$1493.25","1712.26","86","","","Percent of Total Billed Charges","neg_dollar:$1712.26","1393.69","70","","","Percent of Total Billed Charges","neg_dollar:$1393.69","1134.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$1134.87;103.5% of Medicaid interim rate","1991.00","150","","","Percent of Total Billed Charges","neg_dollar:$3078.18;150% of Medicaid interim rate","1592.80","80","","","Percent of Total Billed Charges","neg_dollar:$1592.80;Percent of Total Billed Charges","1831.72","92","","","Percent of Total Billed Charges","neg_dollar:$1831.72","1035.32","52","","","Percent of Total Billed Charges","neg_dollar:$1035.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","1035.32","52","","","Percent of Total Billed Charges","neg_dollar:$1035.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1991.00",""
"STERILE MED/SURG SUPPLY LEVEL 32","","","27100077","CDM","272","RC","","Facility","Outpatient","","","2138","1710.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1111.76","52","","","Percent of Total Billed Charges","neg_dollar:$1111.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1111.76","52","","","Percent of Total Billed Charges","neg_dollar:$1111.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1111.76","52","","","Percent of Total Billed Charges","neg_dollar:$1111.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1111.76","52","","","Percent of Total Billed Charges","neg_dollar:$1111.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","1838.68","86","","","Percent of Total Billed Charges","neg_dollar:$1838.68","1496.60","70","","","Percent of Total Billed Charges","neg_dollar:$1496.60","1111.76","52","","","Percent of Total Billed Charges","neg_dollar:$1111.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","1256.07","56.99","","","Percent of Total Billed Charges","neg_dollar:$1256.07;102% of Medicaid interim rate","1603.50","75","","","Percent of Total Billed Charges","neg_dollar:$1603.50","1838.68","86","","","Percent of Total Billed Charges","neg_dollar:$1838.68","1496.60","70","","","Percent of Total Billed Charges","neg_dollar:$1496.60","1218.65","56.99","","","Percent of Total Billed Charges","neg_dollar:$1218.65;103.5% of Medicaid interim rate","2138.00","150","","","Percent of Total Billed Charges","neg_dollar:$3305.45;150% of Medicaid interim rate","1710.40","80","","","Percent of Total Billed Charges","neg_dollar:$1710.40;Percent of Total Billed Charges","1966.96","92","","","Percent of Total Billed Charges","neg_dollar:$1966.96","1111.76","52","","","Percent of Total Billed Charges","neg_dollar:$1111.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","1111.76","52","","","Percent of Total Billed Charges","neg_dollar:$1111.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2138.00",""
"STERILE MED/SURG SUPPLY LEVEL 33","","","27100078","CDM","272","RC","","Facility","Outpatient","","","2715","2172.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2334.90","86","","","Percent of Total Billed Charges","neg_dollar:$2334.90","1900.49","70","","","Percent of Total Billed Charges","neg_dollar:$1900.49","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","1595.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1595.05;102% of Medicaid interim rate","2036.25","75","","","Percent of Total Billed Charges","neg_dollar:$2036.25","2334.90","86","","","Percent of Total Billed Charges","neg_dollar:$2334.90","1900.49","70","","","Percent of Total Billed Charges","neg_dollar:$1900.49","1547.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$1547.55;103.5% of Medicaid interim rate","2715.00","150","","","Percent of Total Billed Charges","neg_dollar:$4197.52;150% of Medicaid interim rate","2172.00","80","","","Percent of Total Billed Charges","neg_dollar:$2172;Percent of Total Billed Charges","2497.80","92","","","Percent of Total Billed Charges","neg_dollar:$2497.80","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2715.00",""
"STERILE MED/SURG SUPPLY LEVEL 34","","","27100079","CDM","272","RC","","Facility","Outpatient","","","2715","2172.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","2334.90","86","","","Percent of Total Billed Charges","neg_dollar:$2334.90","1900.49","70","","","Percent of Total Billed Charges","neg_dollar:$1900.49","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","1595.05","56.99","","","Percent of Total Billed Charges","neg_dollar:$1595.05;102% of Medicaid interim rate","2036.25","75","","","Percent of Total Billed Charges","neg_dollar:$2036.25","2334.90","86","","","Percent of Total Billed Charges","neg_dollar:$2334.90","1900.49","70","","","Percent of Total Billed Charges","neg_dollar:$1900.49","1547.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$1547.55;103.5% of Medicaid interim rate","2715.00","150","","","Percent of Total Billed Charges","neg_dollar:$4197.52;150% of Medicaid interim rate","2172.00","80","","","Percent of Total Billed Charges","neg_dollar:$2172;Percent of Total Billed Charges","2497.80","92","","","Percent of Total Billed Charges","neg_dollar:$2497.80","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","1411.80","52","","","Percent of Total Billed Charges","neg_dollar:$1411.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2715.00",""
"STERILE MED/SURG SUPPLY LEVEL 35","","","27100080","CDM","272","RC","","Facility","Outpatient","","","3196","2556.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1661.92","52","","","Percent of Total Billed Charges","neg_dollar:$1661.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1661.92","52","","","Percent of Total Billed Charges","neg_dollar:$1661.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1661.92","52","","","Percent of Total Billed Charges","neg_dollar:$1661.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","1661.92","52","","","Percent of Total Billed Charges","neg_dollar:$1661.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2748.56","86","","","Percent of Total Billed Charges","neg_dollar:$2748.56","2237.20","70","","","Percent of Total Billed Charges","neg_dollar:$2237.20","1661.92","52","","","Percent of Total Billed Charges","neg_dollar:$1661.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","1877.64","56.99","","","Percent of Total Billed Charges","neg_dollar:$1877.64;102% of Medicaid interim rate","2397.00","75","","","Percent of Total Billed Charges","neg_dollar:$2397","2748.56","86","","","Percent of Total Billed Charges","neg_dollar:$2748.56","2237.20","70","","","Percent of Total Billed Charges","neg_dollar:$2237.20","1821.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$1821.71;103.5% of Medicaid interim rate","3196.00","150","","","Percent of Total Billed Charges","neg_dollar:$4941.17;150% of Medicaid interim rate","2556.80","80","","","Percent of Total Billed Charges","neg_dollar:$2556.80;Percent of Total Billed Charges","2940.32","92","","","Percent of Total Billed Charges","neg_dollar:$2940.32","1661.92","52","","","Percent of Total Billed Charges","neg_dollar:$1661.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","1661.92","52","","","Percent of Total Billed Charges","neg_dollar:$1661.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3196.00",""
"STERILE MED/SURG SUPPLY LEVEL 36","","","27100081","CDM","272","RC","","Facility","Outpatient","","","1250","1000.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;102% Medicare Outpatient Cost to Charge Ratio of 52%","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;102% Medicare Outpatient Cost to Charge Ratio of 52%","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;102% Medicare Outpatient Cost to Charge Ratio of 52%","1075.00","86","","","Percent of Total Billed Charges","neg_dollar:$1075","875.00","70","","","Percent of Total Billed Charges","neg_dollar:$875","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;105% Medicare Outpatient Cost to Charge Ratio of 52%","734.37","56.99","","","Percent of Total Billed Charges","neg_dollar:$734.37;102% of Medicaid interim rate","937.50","75","","","Percent of Total Billed Charges","neg_dollar:$937.50","1075.00","86","","","Percent of Total Billed Charges","neg_dollar:$1075","875.00","70","","","Percent of Total Billed Charges","neg_dollar:$875","712.49","56.99","","","Percent of Total Billed Charges","neg_dollar:$712.49;103.5% of Medicaid interim rate","1250.00","150","","","Percent of Total Billed Charges","neg_dollar:$1932.56;150% of Medicaid interim rate","1000.00","80","","","Percent of Total Billed Charges","neg_dollar:$1000;Percent of Total Billed Charges","1150.00","92","","","Percent of Total Billed Charges","neg_dollar:$1150","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;100% Medicare Outpatient Cost to Charge Ratio of 52%","650.00","52","","","Percent of Total Billed Charges","neg_dollar:$650;100% Medicare Outpatient Cost to Charge Ratio of 52%","650.00","1250.00",""
"STERILE MED/SURG SUPPLY LEVEL 41","","","27100086","CDM","272","RC","","Facility","Outpatient","","","4377","3501.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2276.04","52","","","Percent of Total Billed Charges","neg_dollar:$2276.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2276.04","52","","","Percent of Total Billed Charges","neg_dollar:$2276.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2276.04","52","","","Percent of Total Billed Charges","neg_dollar:$2276.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2276.04","52","","","Percent of Total Billed Charges","neg_dollar:$2276.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","3764.22","86","","","Percent of Total Billed Charges","neg_dollar:$3764.22","3063.89","70","","","Percent of Total Billed Charges","neg_dollar:$3063.89","2276.04","52","","","Percent of Total Billed Charges","neg_dollar:$2276.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","2571.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$2571.48;102% of Medicaid interim rate","3282.75","75","","","Percent of Total Billed Charges","neg_dollar:$3282.75","3764.22","86","","","Percent of Total Billed Charges","neg_dollar:$3764.22","3063.89","70","","","Percent of Total Billed Charges","neg_dollar:$3063.89","2494.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$2494.89;103.5% of Medicaid interim rate","4377.00","150","","","Percent of Total Billed Charges","neg_dollar:$6767.06;150% of Medicaid interim rate","3501.60","80","","","Percent of Total Billed Charges","neg_dollar:$3501.60;Percent of Total Billed Charges","4026.84","92","","","Percent of Total Billed Charges","neg_dollar:$4026.84","2276.04","52","","","Percent of Total Billed Charges","neg_dollar:$2276.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","2276.04","52","","","Percent of Total Billed Charges","neg_dollar:$2276.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4377.00",""
"STERILE MED/SURG SUPPLY LEVEL 42","","","27100087","CDM","272","RC","","Facility","Outpatient","","","4877","3901.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2536.04","52","","","Percent of Total Billed Charges","neg_dollar:$2536.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2536.04","52","","","Percent of Total Billed Charges","neg_dollar:$2536.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2536.04","52","","","Percent of Total Billed Charges","neg_dollar:$2536.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2536.04","52","","","Percent of Total Billed Charges","neg_dollar:$2536.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","4194.22","86","","","Percent of Total Billed Charges","neg_dollar:$4194.22","3413.89","70","","","Percent of Total Billed Charges","neg_dollar:$3413.89","2536.04","52","","","Percent of Total Billed Charges","neg_dollar:$2536.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","2865.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$2865.23;102% of Medicaid interim rate","3657.75","75","","","Percent of Total Billed Charges","neg_dollar:$3657.75","4194.22","86","","","Percent of Total Billed Charges","neg_dollar:$4194.22","3413.89","70","","","Percent of Total Billed Charges","neg_dollar:$3413.89","2779.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$2779.89;103.5% of Medicaid interim rate","4877.00","150","","","Percent of Total Billed Charges","neg_dollar:$7540.08;150% of Medicaid interim rate","3901.60","80","","","Percent of Total Billed Charges","neg_dollar:$3901.60;Percent of Total Billed Charges","4486.84","92","","","Percent of Total Billed Charges","neg_dollar:$4486.84","2536.04","52","","","Percent of Total Billed Charges","neg_dollar:$2536.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","2536.04","52","","","Percent of Total Billed Charges","neg_dollar:$2536.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4877.00",""
"CAST ORTHO SOFT GOODS LEVEL 1","","","27100091","CDM","270","RC","","Facility","Outpatient","","","44","35.20","44.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","22.88","52","","","Percent of Total Billed Charges","neg_dollar:$22.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","44.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","22.88","52","","","Percent of Total Billed Charges","neg_dollar:$22.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","22.88","52","","","Percent of Total Billed Charges","neg_dollar:$22.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","22.88","52","","","Percent of Total Billed Charges","neg_dollar:$22.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","37.83","86","","","Percent of Total Billed Charges","neg_dollar:$37.83","30.79","70","","","Percent of Total Billed Charges","neg_dollar:$30.79","22.88","52","","","Percent of Total Billed Charges","neg_dollar:$22.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","25.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.84;102% of Medicaid interim rate","33.00","75","","","Percent of Total Billed Charges","neg_dollar:$33","37.83","86","","","Percent of Total Billed Charges","neg_dollar:$37.83","30.79","70","","","Percent of Total Billed Charges","neg_dollar:$30.79","25.08","56.99","","","Percent of Total Billed Charges","neg_dollar:$25.08;103.5% of Medicaid interim rate","44.00","150","","","Percent of Total Billed Charges","neg_dollar:$68.02;150% of Medicaid interim rate","35.20","80","","","Percent of Total Billed Charges","neg_dollar:$35.20;Percent of Total Billed Charges","40.48","92","","","Percent of Total Billed Charges","neg_dollar:$40.48","22.88","52","","","Percent of Total Billed Charges","neg_dollar:$22.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","22.88","52","","","Percent of Total Billed Charges","neg_dollar:$22.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","22.00","44.00",""
"CAST ORTHO SOFT GOODS LEVEL 2","","","27100092","CDM","270","RC","","Facility","Outpatient","","","96","76.80","96.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","49.92","52","","","Percent of Total Billed Charges","neg_dollar:$49.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","96.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","49.92","52","","","Percent of Total Billed Charges","neg_dollar:$49.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","49.92","52","","","Percent of Total Billed Charges","neg_dollar:$49.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","49.92","52","","","Percent of Total Billed Charges","neg_dollar:$49.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","82.56","86","","","Percent of Total Billed Charges","neg_dollar:$82.56","67.19","70","","","Percent of Total Billed Charges","neg_dollar:$67.19","49.92","52","","","Percent of Total Billed Charges","neg_dollar:$49.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","56.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$56.39;102% of Medicaid interim rate","72.00","75","","","Percent of Total Billed Charges","neg_dollar:$72","82.56","86","","","Percent of Total Billed Charges","neg_dollar:$82.56","67.19","70","","","Percent of Total Billed Charges","neg_dollar:$67.19","54.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$54.72;103.5% of Medicaid interim rate","96.00","150","","","Percent of Total Billed Charges","neg_dollar:$148.42;150% of Medicaid interim rate","76.80","80","","","Percent of Total Billed Charges","neg_dollar:$76.80;Percent of Total Billed Charges","88.32","92","","","Percent of Total Billed Charges","neg_dollar:$88.32","49.92","52","","","Percent of Total Billed Charges","neg_dollar:$49.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","49.92","52","","","Percent of Total Billed Charges","neg_dollar:$49.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","49.00","96.00",""
"CAST ORTHO SOFT GOODS LEVEL 3","","","27100093","CDM","270","RC","","Facility","Outpatient","","","113","90.40","113.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","113.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","97.17","86","","","Percent of Total Billed Charges","neg_dollar:$97.17","79.10","70","","","Percent of Total Billed Charges","neg_dollar:$79.10","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","66.38","56.99","","","Percent of Total Billed Charges","neg_dollar:$66.38;102% of Medicaid interim rate","84.75","75","","","Percent of Total Billed Charges","neg_dollar:$84.75","97.17","86","","","Percent of Total Billed Charges","neg_dollar:$97.17","79.10","70","","","Percent of Total Billed Charges","neg_dollar:$79.10","64.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$64.41;103.5% of Medicaid interim rate","113.00","150","","","Percent of Total Billed Charges","neg_dollar:$174.70;150% of Medicaid interim rate","90.40","80","","","Percent of Total Billed Charges","neg_dollar:$90.40;Percent of Total Billed Charges","103.96","92","","","Percent of Total Billed Charges","neg_dollar:$103.96","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.76","52","","","Percent of Total Billed Charges","neg_dollar:$58.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","58.00","113.00",""
"CAST ORTHO SOFT GOODS LEVEL 4","","","27100094","CDM","270","RC","","Facility","Outpatient","","","147","117.60","147.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","147.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","126.42","86","","","Percent of Total Billed Charges","neg_dollar:$126.42","102.89","70","","","Percent of Total Billed Charges","neg_dollar:$102.89","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","86.36","56.99","","","Percent of Total Billed Charges","neg_dollar:$86.36;102% of Medicaid interim rate","110.25","75","","","Percent of Total Billed Charges","neg_dollar:$110.25","126.42","86","","","Percent of Total Billed Charges","neg_dollar:$126.42","102.89","70","","","Percent of Total Billed Charges","neg_dollar:$102.89","83.78","56.99","","","Percent of Total Billed Charges","neg_dollar:$83.78;103.5% of Medicaid interim rate","147.00","150","","","Percent of Total Billed Charges","neg_dollar:$227.26;150% of Medicaid interim rate","117.60","80","","","Percent of Total Billed Charges","neg_dollar:$117.60;Percent of Total Billed Charges","135.24","92","","","Percent of Total Billed Charges","neg_dollar:$135.24","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","76.44","52","","","Percent of Total Billed Charges","neg_dollar:$76.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","76.00","147.00",""
"CAST ORTHO SOFT GOODS LEVEL 5","","","27100095","CDM","270","RC","","Facility","Outpatient","","","162","129.60","162.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;101% Medicare Outpatient Cost to Charge Ratio of 52%","162.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;102% Medicare Outpatient Cost to Charge Ratio of 52%","139.32","86","","","Percent of Total Billed Charges","neg_dollar:$139.32","113.39","70","","","Percent of Total Billed Charges","neg_dollar:$113.39","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;105% Medicare Outpatient Cost to Charge Ratio of 52%","95.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$95.17;102% of Medicaid interim rate","121.50","75","","","Percent of Total Billed Charges","neg_dollar:$121.50","139.32","86","","","Percent of Total Billed Charges","neg_dollar:$139.32","113.39","70","","","Percent of Total Billed Charges","neg_dollar:$113.39","92.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$92.33;103.5% of Medicaid interim rate","162.00","150","","","Percent of Total Billed Charges","neg_dollar:$250.46;150% of Medicaid interim rate","129.60","80","","","Percent of Total Billed Charges","neg_dollar:$129.60;Percent of Total Billed Charges","149.04","92","","","Percent of Total Billed Charges","neg_dollar:$149.04","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","84.24","52","","","Percent of Total Billed Charges","neg_dollar:$84.24;100% Medicare Outpatient Cost to Charge Ratio of 52%","84.00","162.00",""
"CAST ORTHO SOFT GOODS LEVEL 6","","","27100096","CDM","270","RC","","Facility","Outpatient","","","205","164.00","205.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","205.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","176.30","86","","","Percent of Total Billed Charges","neg_dollar:$176.30","143.50","70","","","Percent of Total Billed Charges","neg_dollar:$143.50","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","120.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$120.43;102% of Medicaid interim rate","153.75","75","","","Percent of Total Billed Charges","neg_dollar:$153.75","176.30","86","","","Percent of Total Billed Charges","neg_dollar:$176.30","143.50","70","","","Percent of Total Billed Charges","neg_dollar:$143.50","116.85","56.99","","","Percent of Total Billed Charges","neg_dollar:$116.85;103.5% of Medicaid interim rate","205.00","150","","","Percent of Total Billed Charges","neg_dollar:$316.94;150% of Medicaid interim rate","164.00","80","","","Percent of Total Billed Charges","neg_dollar:$164;Percent of Total Billed Charges","188.60","92","","","Percent of Total Billed Charges","neg_dollar:$188.60","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","106.60","52","","","Percent of Total Billed Charges","neg_dollar:$106.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","106.00","205.00",""
"CAST ORTHO SOFT GOODS LEVEL 7","","","27100097","CDM","270","RC","","Facility","Outpatient","","","246","196.80","246.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","127.92","52","","","Percent of Total Billed Charges","neg_dollar:$127.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","246.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","127.92","52","","","Percent of Total Billed Charges","neg_dollar:$127.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","127.92","52","","","Percent of Total Billed Charges","neg_dollar:$127.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","127.92","52","","","Percent of Total Billed Charges","neg_dollar:$127.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","211.56","86","","","Percent of Total Billed Charges","neg_dollar:$211.56","172.20","70","","","Percent of Total Billed Charges","neg_dollar:$172.20","127.92","52","","","Percent of Total Billed Charges","neg_dollar:$127.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","144.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$144.52;102% of Medicaid interim rate","184.50","75","","","Percent of Total Billed Charges","neg_dollar:$184.50","211.56","86","","","Percent of Total Billed Charges","neg_dollar:$211.56","172.20","70","","","Percent of Total Billed Charges","neg_dollar:$172.20","140.22","56.99","","","Percent of Total Billed Charges","neg_dollar:$140.22;103.5% of Medicaid interim rate","246.00","150","","","Percent of Total Billed Charges","neg_dollar:$380.32;150% of Medicaid interim rate","196.80","80","","","Percent of Total Billed Charges","neg_dollar:$196.80;Percent of Total Billed Charges","226.32","92","","","Percent of Total Billed Charges","neg_dollar:$226.32","127.92","52","","","Percent of Total Billed Charges","neg_dollar:$127.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","127.92","52","","","Percent of Total Billed Charges","neg_dollar:$127.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","127.00","246.00",""
"CAST ORTHO SOFT GOODS LEVEL 8","","","27100098","CDM","270","RC","","Facility","Outpatient","","","297","237.60","297.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","297.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","174.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$174.48;102% of Medicaid interim rate","222.75","75","","","Percent of Total Billed Charges","neg_dollar:$222.75","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","169.29","56.99","","","Percent of Total Billed Charges","neg_dollar:$169.29;103.5% of Medicaid interim rate","297.00","150","","","Percent of Total Billed Charges","neg_dollar:$459.17;150% of Medicaid interim rate","237.60","80","","","Percent of Total Billed Charges","neg_dollar:$237.60;Percent of Total Billed Charges","273.24","92","","","Percent of Total Billed Charges","neg_dollar:$273.24","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","154.44","52","","","Percent of Total Billed Charges","neg_dollar:$154.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","154.00","297.00",""
"CAST ORTHO SOFT GOODS LEVEL 9","","","27100099","CDM","270","RC","","Facility","Outpatient","","","329","263.20","329.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","329.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","282.94","86","","","Percent of Total Billed Charges","neg_dollar:$282.94","230.29","70","","","Percent of Total Billed Charges","neg_dollar:$230.29","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","193.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$193.28;102% of Medicaid interim rate","246.75","75","","","Percent of Total Billed Charges","neg_dollar:$246.75","282.94","86","","","Percent of Total Billed Charges","neg_dollar:$282.94","230.29","70","","","Percent of Total Billed Charges","neg_dollar:$230.29","187.52","56.99","","","Percent of Total Billed Charges","neg_dollar:$187.52;103.5% of Medicaid interim rate","329.00","150","","","Percent of Total Billed Charges","neg_dollar:$508.65;150% of Medicaid interim rate","263.20","80","","","Percent of Total Billed Charges","neg_dollar:$263.20;Percent of Total Billed Charges","302.68","92","","","Percent of Total Billed Charges","neg_dollar:$302.68","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","171.08","52","","","Percent of Total Billed Charges","neg_dollar:$171.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","171.00","329.00",""
"CAST ORTHO SOFT GOODS LEVEL 10","","","27100100","CDM","270","RC","","Facility","Outpatient","","","480","384.00","480.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","249.60","52","","","Percent of Total Billed Charges","neg_dollar:$249.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","480.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","249.60","52","","","Percent of Total Billed Charges","neg_dollar:$249.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","249.60","52","","","Percent of Total Billed Charges","neg_dollar:$249.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","249.60","52","","","Percent of Total Billed Charges","neg_dollar:$249.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","412.80","86","","","Percent of Total Billed Charges","neg_dollar:$412.80","336.00","70","","","Percent of Total Billed Charges","neg_dollar:$336","249.60","52","","","Percent of Total Billed Charges","neg_dollar:$249.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","281.99","56.99","","","Percent of Total Billed Charges","neg_dollar:$281.99;102% of Medicaid interim rate","360.00","75","","","Percent of Total Billed Charges","neg_dollar:$360","412.80","86","","","Percent of Total Billed Charges","neg_dollar:$412.80","336.00","70","","","Percent of Total Billed Charges","neg_dollar:$336","273.59","56.99","","","Percent of Total Billed Charges","neg_dollar:$273.59;103.5% of Medicaid interim rate","480.00","150","","","Percent of Total Billed Charges","neg_dollar:$742.10;150% of Medicaid interim rate","384.00","80","","","Percent of Total Billed Charges","neg_dollar:$384;Percent of Total Billed Charges","441.60","92","","","Percent of Total Billed Charges","neg_dollar:$441.60","249.60","52","","","Percent of Total Billed Charges","neg_dollar:$249.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","249.60","52","","","Percent of Total Billed Charges","neg_dollar:$249.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","249.00","480.00",""
"CAST ORTHO SOFT GOODS LEVEL 11","","","27100101","CDM","270","RC","","Facility","Outpatient","","","503","402.40","503.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","261.56","52","","","Percent of Total Billed Charges","neg_dollar:$261.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","503.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","261.56","52","","","Percent of Total Billed Charges","neg_dollar:$261.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","261.56","52","","","Percent of Total Billed Charges","neg_dollar:$261.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","261.56","52","","","Percent of Total Billed Charges","neg_dollar:$261.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","432.58","86","","","Percent of Total Billed Charges","neg_dollar:$432.58","352.09","70","","","Percent of Total Billed Charges","neg_dollar:$352.09","261.56","52","","","Percent of Total Billed Charges","neg_dollar:$261.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","295.51","56.99","","","Percent of Total Billed Charges","neg_dollar:$295.51;102% of Medicaid interim rate","377.25","75","","","Percent of Total Billed Charges","neg_dollar:$377.25","432.58","86","","","Percent of Total Billed Charges","neg_dollar:$432.58","352.09","70","","","Percent of Total Billed Charges","neg_dollar:$352.09","286.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$286.71;103.5% of Medicaid interim rate","503.00","150","","","Percent of Total Billed Charges","neg_dollar:$777.66;150% of Medicaid interim rate","402.40","80","","","Percent of Total Billed Charges","neg_dollar:$402.40;Percent of Total Billed Charges","462.76","92","","","Percent of Total Billed Charges","neg_dollar:$462.76","261.56","52","","","Percent of Total Billed Charges","neg_dollar:$261.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","261.56","52","","","Percent of Total Billed Charges","neg_dollar:$261.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","261.00","503.00",""
"MISC IMPLANT CHARGE LEVEL 1","","","27100107","CDM","278","RC","","Facility","Outpatient","","","306","244.80","306.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;101% Medicare Outpatient Cost to Charge Ratio of 52%","306.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;102% Medicare Outpatient Cost to Charge Ratio of 52%","263.15","86","","","Percent of Total Billed Charges","neg_dollar:$263.15","214.20","70","","","Percent of Total Billed Charges","neg_dollar:$214.20","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;105% Medicare Outpatient Cost to Charge Ratio of 52%","179.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$179.77;102% of Medicaid interim rate","229.50","75","","","Percent of Total Billed Charges","neg_dollar:$229.50","263.15","86","","","Percent of Total Billed Charges","neg_dollar:$263.15","214.20","70","","","Percent of Total Billed Charges","neg_dollar:$214.20","174.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$174.42;103.5% of Medicaid interim rate","306.00","150","","","Percent of Total Billed Charges","neg_dollar:$473.09;150% of Medicaid interim rate","244.80","80","","","Percent of Total Billed Charges","neg_dollar:$244.80;Percent of Total Billed Charges","281.52","92","","","Percent of Total Billed Charges","neg_dollar:$281.52","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","159.12","52","","","Percent of Total Billed Charges","neg_dollar:$159.12;100% Medicare Outpatient Cost to Charge Ratio of 52%","159.00","306.00",""
"MISC IMPLANT CHARGE LEVEL 2","","","27100108","CDM","278","RC","","Facility","Outpatient","","","318","254.40","318.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","318.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","273.48","86","","","Percent of Total Billed Charges","neg_dollar:$273.48","222.60","70","","","Percent of Total Billed Charges","neg_dollar:$222.60","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","186.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$186.82;102% of Medicaid interim rate","238.50","75","","","Percent of Total Billed Charges","neg_dollar:$238.50","273.48","86","","","Percent of Total Billed Charges","neg_dollar:$273.48","222.60","70","","","Percent of Total Billed Charges","neg_dollar:$222.60","181.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$181.26;103.5% of Medicaid interim rate","318.00","150","","","Percent of Total Billed Charges","neg_dollar:$491.64;150% of Medicaid interim rate","254.40","80","","","Percent of Total Billed Charges","neg_dollar:$254.40;Percent of Total Billed Charges","292.56","92","","","Percent of Total Billed Charges","neg_dollar:$292.56","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","165.36","52","","","Percent of Total Billed Charges","neg_dollar:$165.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","165.00","318.00",""
"MISC IMPLANT CHARGE LEVEL 3","","","27100109","CDM","278","RC","","Facility","Outpatient","","","622","497.60","622.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","323.44","52","","","Percent of Total Billed Charges","neg_dollar:$323.44;101% Medicare Outpatient Cost to Charge Ratio of 52%","622.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","323.44","52","","","Percent of Total Billed Charges","neg_dollar:$323.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","323.44","52","","","Percent of Total Billed Charges","neg_dollar:$323.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","323.44","52","","","Percent of Total Billed Charges","neg_dollar:$323.44;102% Medicare Outpatient Cost to Charge Ratio of 52%","534.92","86","","","Percent of Total Billed Charges","neg_dollar:$534.92","435.40","70","","","Percent of Total Billed Charges","neg_dollar:$435.40","323.44","52","","","Percent of Total Billed Charges","neg_dollar:$323.44;105% Medicare Outpatient Cost to Charge Ratio of 52%","365.42","56.99","","","Percent of Total Billed Charges","neg_dollar:$365.42;102% of Medicaid interim rate","466.50","75","","","Percent of Total Billed Charges","neg_dollar:$466.50","534.92","86","","","Percent of Total Billed Charges","neg_dollar:$534.92","435.40","70","","","Percent of Total Billed Charges","neg_dollar:$435.40","354.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$354.53;103.5% of Medicaid interim rate","622.00","150","","","Percent of Total Billed Charges","neg_dollar:$961.64;150% of Medicaid interim rate","497.60","80","","","Percent of Total Billed Charges","neg_dollar:$497.60;Percent of Total Billed Charges","572.24","92","","","Percent of Total Billed Charges","neg_dollar:$572.24","323.44","52","","","Percent of Total Billed Charges","neg_dollar:$323.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","323.44","52","","","Percent of Total Billed Charges","neg_dollar:$323.44;100% Medicare Outpatient Cost to Charge Ratio of 52%","323.00","622.00",""
"MISC IMPLANT CHARGE LEVEL 4","","","27100110","CDM","278","RC","","Facility","Outpatient","","","924","739.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","480.48","52","","","Percent of Total Billed Charges","neg_dollar:$480.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","480.48","52","","","Percent of Total Billed Charges","neg_dollar:$480.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","480.48","52","","","Percent of Total Billed Charges","neg_dollar:$480.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","480.48","52","","","Percent of Total Billed Charges","neg_dollar:$480.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","794.64","86","","","Percent of Total Billed Charges","neg_dollar:$794.64","646.80","70","","","Percent of Total Billed Charges","neg_dollar:$646.80","480.48","52","","","Percent of Total Billed Charges","neg_dollar:$480.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","542.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$542.84;102% of Medicaid interim rate","693.00","75","","","Percent of Total Billed Charges","neg_dollar:$693","794.64","86","","","Percent of Total Billed Charges","neg_dollar:$794.64","646.80","70","","","Percent of Total Billed Charges","neg_dollar:$646.80","526.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$526.68;103.5% of Medicaid interim rate","924.00","150","","","Percent of Total Billed Charges","neg_dollar:$1428.55;150% of Medicaid interim rate","739.20","80","","","Percent of Total Billed Charges","neg_dollar:$739.20;Percent of Total Billed Charges","850.08","92","","","Percent of Total Billed Charges","neg_dollar:$850.08","480.48","52","","","Percent of Total Billed Charges","neg_dollar:$480.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","480.48","52","","","Percent of Total Billed Charges","neg_dollar:$480.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","480.00","924.00",""
"MISC IMPLANT CHARGE LEVEL 5","","","27100111","CDM","278","RC","","Facility","Outpatient","","","1229","983.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","639.08","52","","","Percent of Total Billed Charges","neg_dollar:$639.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","639.08","52","","","Percent of Total Billed Charges","neg_dollar:$639.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","639.08","52","","","Percent of Total Billed Charges","neg_dollar:$639.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","639.08","52","","","Percent of Total Billed Charges","neg_dollar:$639.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","1056.94","86","","","Percent of Total Billed Charges","neg_dollar:$1056.94","860.30","70","","","Percent of Total Billed Charges","neg_dollar:$860.30","639.08","52","","","Percent of Total Billed Charges","neg_dollar:$639.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","722.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$722.03;102% of Medicaid interim rate","921.75","75","","","Percent of Total Billed Charges","neg_dollar:$921.75","1056.94","86","","","Percent of Total Billed Charges","neg_dollar:$1056.94","860.30","70","","","Percent of Total Billed Charges","neg_dollar:$860.30","700.53","56.99","","","Percent of Total Billed Charges","neg_dollar:$700.53;103.5% of Medicaid interim rate","1229.00","150","","","Percent of Total Billed Charges","neg_dollar:$1900.09;150% of Medicaid interim rate","983.20","80","","","Percent of Total Billed Charges","neg_dollar:$983.20;Percent of Total Billed Charges","1130.68","92","","","Percent of Total Billed Charges","neg_dollar:$1130.68","639.08","52","","","Percent of Total Billed Charges","neg_dollar:$639.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","639.08","52","","","Percent of Total Billed Charges","neg_dollar:$639.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","639.00","1229.00",""
"MISC IMPLANT CHARGE LEVEL 6","","","27100112","CDM","278","RC","","Facility","Outpatient","","","1532","1225.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","796.64","52","","","Percent of Total Billed Charges","neg_dollar:$796.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","796.64","52","","","Percent of Total Billed Charges","neg_dollar:$796.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","796.64","52","","","Percent of Total Billed Charges","neg_dollar:$796.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","796.64","52","","","Percent of Total Billed Charges","neg_dollar:$796.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1317.52","86","","","Percent of Total Billed Charges","neg_dollar:$1317.52","1072.39","70","","","Percent of Total Billed Charges","neg_dollar:$1072.39","796.64","52","","","Percent of Total Billed Charges","neg_dollar:$796.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","900.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$900.04;102% of Medicaid interim rate","1149.00","75","","","Percent of Total Billed Charges","neg_dollar:$1149","1317.52","86","","","Percent of Total Billed Charges","neg_dollar:$1317.52","1072.39","70","","","Percent of Total Billed Charges","neg_dollar:$1072.39","873.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$873.23;103.5% of Medicaid interim rate","1532.00","150","","","Percent of Total Billed Charges","neg_dollar:$2368.54;150% of Medicaid interim rate","1225.60","80","","","Percent of Total Billed Charges","neg_dollar:$1225.60;Percent of Total Billed Charges","1409.44","92","","","Percent of Total Billed Charges","neg_dollar:$1409.44","796.64","52","","","Percent of Total Billed Charges","neg_dollar:$796.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","796.64","52","","","Percent of Total Billed Charges","neg_dollar:$796.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","1532.00",""
"MISC IMPLANT CHARGE LEVEL 7","","","27100113","CDM","278","RC","","Facility","Outpatient","","","3053","2442.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1587.56","52","","","Percent of Total Billed Charges","neg_dollar:$1587.56;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1587.56","52","","","Percent of Total Billed Charges","neg_dollar:$1587.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1587.56","52","","","Percent of Total Billed Charges","neg_dollar:$1587.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","1587.56","52","","","Percent of Total Billed Charges","neg_dollar:$1587.56;102% Medicare Outpatient Cost to Charge Ratio of 52%","2625.58","86","","","Percent of Total Billed Charges","neg_dollar:$2625.58","2137.10","70","","","Percent of Total Billed Charges","neg_dollar:$2137.10","1587.56","52","","","Percent of Total Billed Charges","neg_dollar:$1587.56;105% Medicare Outpatient Cost to Charge Ratio of 52%","1793.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$1793.63;102% of Medicaid interim rate","2289.75","75","","","Percent of Total Billed Charges","neg_dollar:$2289.75","2625.58","86","","","Percent of Total Billed Charges","neg_dollar:$2625.58","2137.10","70","","","Percent of Total Billed Charges","neg_dollar:$2137.10","1740.20","56.99","","","Percent of Total Billed Charges","neg_dollar:$1740.20;103.5% of Medicaid interim rate","3053.00","150","","","Percent of Total Billed Charges","neg_dollar:$4720.09;150% of Medicaid interim rate","2442.40","80","","","Percent of Total Billed Charges","neg_dollar:$2442.40;Percent of Total Billed Charges","2808.76","92","","","Percent of Total Billed Charges","neg_dollar:$2808.76","1587.56","52","","","Percent of Total Billed Charges","neg_dollar:$1587.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","1587.56","52","","","Percent of Total Billed Charges","neg_dollar:$1587.56;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","3053.00",""
"MISC IMPLANT CHARGE LEVEL 8","","","27100114","CDM","278","RC","","Facility","Outpatient","","","4571","3656.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2376.92","52","","","Percent of Total Billed Charges","neg_dollar:$2376.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2376.92","52","","","Percent of Total Billed Charges","neg_dollar:$2376.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2376.92","52","","","Percent of Total Billed Charges","neg_dollar:$2376.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","2376.92","52","","","Percent of Total Billed Charges","neg_dollar:$2376.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","3931.06","86","","","Percent of Total Billed Charges","neg_dollar:$3931.06","3199.70","70","","","Percent of Total Billed Charges","neg_dollar:$3199.70","2376.92","52","","","Percent of Total Billed Charges","neg_dollar:$2376.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","2685.45","56.99","","","Percent of Total Billed Charges","neg_dollar:$2685.45;102% of Medicaid interim rate","3428.25","75","","","Percent of Total Billed Charges","neg_dollar:$3428.25","3931.06","86","","","Percent of Total Billed Charges","neg_dollar:$3931.06","3199.70","70","","","Percent of Total Billed Charges","neg_dollar:$3199.70","2605.47","56.99","","","Percent of Total Billed Charges","neg_dollar:$2605.47;103.5% of Medicaid interim rate","4571.00","150","","","Percent of Total Billed Charges","neg_dollar:$7066.99;150% of Medicaid interim rate","3656.80","80","","","Percent of Total Billed Charges","neg_dollar:$3656.80;Percent of Total Billed Charges","4205.32","92","","","Percent of Total Billed Charges","neg_dollar:$4205.32","2376.92","52","","","Percent of Total Billed Charges","neg_dollar:$2376.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","2376.92","52","","","Percent of Total Billed Charges","neg_dollar:$2376.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4571.00",""
"MISC IMPLANT CHARGE LEVEL 9","","","27100115","CDM","278","RC","","Facility","Outpatient","","","6092","4873.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","3167.84","52","","","Percent of Total Billed Charges","neg_dollar:$3167.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","3167.84","52","","","Percent of Total Billed Charges","neg_dollar:$3167.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","3167.84","52","","","Percent of Total Billed Charges","neg_dollar:$3167.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","3167.84","52","","","Percent of Total Billed Charges","neg_dollar:$3167.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","5239.12","86","","","Percent of Total Billed Charges","neg_dollar:$5239.12","4264.40","70","","","Percent of Total Billed Charges","neg_dollar:$4264.40","3167.84","52","","","Percent of Total Billed Charges","neg_dollar:$3167.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","3579.04","56.99","","","Percent of Total Billed Charges","neg_dollar:$3579.04;102% of Medicaid interim rate","4569.00","75","","","Percent of Total Billed Charges","neg_dollar:$4569","5239.12","86","","","Percent of Total Billed Charges","neg_dollar:$5239.12","4264.40","70","","","Percent of Total Billed Charges","neg_dollar:$4264.40","3472.43","56.99","","","Percent of Total Billed Charges","neg_dollar:$3472.43;103.5% of Medicaid interim rate","6092.00","150","","","Percent of Total Billed Charges","neg_dollar:$9418.53;150% of Medicaid interim rate","4873.60","80","","","Percent of Total Billed Charges","neg_dollar:$4873.60;Percent of Total Billed Charges","5604.64","92","","","Percent of Total Billed Charges","neg_dollar:$5604.64","3167.84","52","","","Percent of Total Billed Charges","neg_dollar:$3167.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","3167.84","52","","","Percent of Total Billed Charges","neg_dollar:$3167.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","6092.00",""
"IV SOLUTION 500 ML","","","27100130","CDM","258","RC","","Facility","Outpatient","","","101","80.80","101.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","101.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","86.86","86","","","Percent of Total Billed Charges","neg_dollar:$86.86","70.69","70","","","Percent of Total Billed Charges","neg_dollar:$70.69","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","59.33","56.99","","","Percent of Total Billed Charges","neg_dollar:$59.33;102% of Medicaid interim rate","75.75","75","","","Percent of Total Billed Charges","neg_dollar:$75.75","86.86","86","","","Percent of Total Billed Charges","neg_dollar:$86.86","70.69","70","","","Percent of Total Billed Charges","neg_dollar:$70.69","57.56","56.99","","","Percent of Total Billed Charges","neg_dollar:$57.56;103.5% of Medicaid interim rate","101.00","150","","","Percent of Total Billed Charges","neg_dollar:$156.15;150% of Medicaid interim rate","80.80","80","","","Percent of Total Billed Charges","neg_dollar:$80.80;Percent of Total Billed Charges","92.92","92","","","Percent of Total Billed Charges","neg_dollar:$92.92","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","52.52","52","","","Percent of Total Billed Charges","neg_dollar:$52.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","52.00","101.00",""
"IV SOLUTION 1000 ML","","","27100131","CDM","258","RC","","Facility","Outpatient","","","124","99.20","124.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","64.48","52","","","Percent of Total Billed Charges","neg_dollar:$64.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","124.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","64.48","52","","","Percent of Total Billed Charges","neg_dollar:$64.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","64.48","52","","","Percent of Total Billed Charges","neg_dollar:$64.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","64.48","52","","","Percent of Total Billed Charges","neg_dollar:$64.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","106.64","86","","","Percent of Total Billed Charges","neg_dollar:$106.64","86.80","70","","","Percent of Total Billed Charges","neg_dollar:$86.80","64.48","52","","","Percent of Total Billed Charges","neg_dollar:$64.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","72.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$72.84;102% of Medicaid interim rate","93.00","75","","","Percent of Total Billed Charges","neg_dollar:$93","106.64","86","","","Percent of Total Billed Charges","neg_dollar:$106.64","86.80","70","","","Percent of Total Billed Charges","neg_dollar:$86.80","70.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$70.67;103.5% of Medicaid interim rate","124.00","150","","","Percent of Total Billed Charges","neg_dollar:$191.71;150% of Medicaid interim rate","99.20","80","","","Percent of Total Billed Charges","neg_dollar:$99.20;Percent of Total Billed Charges","114.08","92","","","Percent of Total Billed Charges","neg_dollar:$114.08","64.48","52","","","Percent of Total Billed Charges","neg_dollar:$64.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","64.48","52","","","Percent of Total Billed Charges","neg_dollar:$64.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","64.00","124.00",""
"MISC IMPLANT CHARGE LEVEL 20","","","27100141","CDM","278","RC","","Facility","Outpatient","","","18338","14670.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","9535.76","52","","","Percent of Total Billed Charges","neg_dollar:$9535.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","9535.76","52","","","Percent of Total Billed Charges","neg_dollar:$9535.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","9535.76","52","","","Percent of Total Billed Charges","neg_dollar:$9535.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","9535.76","52","","","Percent of Total Billed Charges","neg_dollar:$9535.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","15770.68","86","","","Percent of Total Billed Charges","neg_dollar:$15770.68","12836.59","70","","","Percent of Total Billed Charges","neg_dollar:$12836.59","9535.76","52","","","Percent of Total Billed Charges","neg_dollar:$9535.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","10773.55","56.99","","","Percent of Total Billed Charges","neg_dollar:$10773.55;102% of Medicaid interim rate","13753.50","75","","","Percent of Total Billed Charges","neg_dollar:$13753.50","15770.68","86","","","Percent of Total Billed Charges","neg_dollar:$15770.68","12836.59","70","","","Percent of Total Billed Charges","neg_dollar:$12836.59","10452.66","56.99","","","Percent of Total Billed Charges","neg_dollar:$10452.66;103.5% of Medicaid interim rate","18338.00","150","","","Percent of Total Billed Charges","neg_dollar:$28351.46;150% of Medicaid interim rate","14670.40","80","","","Percent of Total Billed Charges","neg_dollar:$14670.40;Percent of Total Billed Charges","16870.96","92","","","Percent of Total Billed Charges","neg_dollar:$16870.96","9535.76","52","","","Percent of Total Billed Charges","neg_dollar:$9535.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","9535.76","52","","","Percent of Total Billed Charges","neg_dollar:$9535.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","18338.00",""
"STERILE MED/SURG SUPPLY LEVEL 51","","","27100159","CDM","272","RC","","Facility","Outpatient","","","10796","8636.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","5613.92","52","","","Percent of Total Billed Charges","neg_dollar:$5613.92;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","5613.92","52","","","Percent of Total Billed Charges","neg_dollar:$5613.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","5613.92","52","","","Percent of Total Billed Charges","neg_dollar:$5613.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","5613.92","52","","","Percent of Total Billed Charges","neg_dollar:$5613.92;102% Medicare Outpatient Cost to Charge Ratio of 52%","9284.56","86","","","Percent of Total Billed Charges","neg_dollar:$9284.56","7557.20","70","","","Percent of Total Billed Charges","neg_dollar:$7557.20","5613.92","52","","","Percent of Total Billed Charges","neg_dollar:$5613.92;105% Medicare Outpatient Cost to Charge Ratio of 52%","6342.63","56.99","","","Percent of Total Billed Charges","neg_dollar:$6342.63;102% of Medicaid interim rate","8097.00","75","","","Percent of Total Billed Charges","neg_dollar:$8097","9284.56","86","","","Percent of Total Billed Charges","neg_dollar:$9284.56","7557.20","70","","","Percent of Total Billed Charges","neg_dollar:$7557.20","6153.71","56.99","","","Percent of Total Billed Charges","neg_dollar:$6153.71;103.5% of Medicaid interim rate","10796.00","150","","","Percent of Total Billed Charges","neg_dollar:$16691.15;150% of Medicaid interim rate","8636.80","80","","","Percent of Total Billed Charges","neg_dollar:$8636.80;Percent of Total Billed Charges","9932.32","92","","","Percent of Total Billed Charges","neg_dollar:$9932.32","5613.92","52","","","Percent of Total Billed Charges","neg_dollar:$5613.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","5613.92","52","","","Percent of Total Billed Charges","neg_dollar:$5613.92;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","10796.00",""
"MED/SURG SUPPLY LEVEL 51","","","27100163","CDM","270","RC","","Facility","Outpatient","","","6563","5250.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","3412.76","52","","","Percent of Total Billed Charges","neg_dollar:$3412.76;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","3412.76","52","","","Percent of Total Billed Charges","neg_dollar:$3412.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","3412.76","52","","","Percent of Total Billed Charges","neg_dollar:$3412.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","3412.76","52","","","Percent of Total Billed Charges","neg_dollar:$3412.76;102% Medicare Outpatient Cost to Charge Ratio of 52%","5644.18","86","","","Percent of Total Billed Charges","neg_dollar:$5644.18","4594.09","70","","","Percent of Total Billed Charges","neg_dollar:$4594.09","3412.76","52","","","Percent of Total Billed Charges","neg_dollar:$3412.76;105% Medicare Outpatient Cost to Charge Ratio of 52%","3855.75","56.99","","","Percent of Total Billed Charges","neg_dollar:$3855.75;102% of Medicaid interim rate","4922.25","75","","","Percent of Total Billed Charges","neg_dollar:$4922.25","5644.18","86","","","Percent of Total Billed Charges","neg_dollar:$5644.18","4594.09","70","","","Percent of Total Billed Charges","neg_dollar:$4594.09","3740.91","56.99","","","Percent of Total Billed Charges","neg_dollar:$3740.91;103.5% of Medicaid interim rate","6563.00","150","","","Percent of Total Billed Charges","neg_dollar:$10146.72;150% of Medicaid interim rate","5250.40","80","","","Percent of Total Billed Charges","neg_dollar:$5250.40;Percent of Total Billed Charges","6037.96","92","","","Percent of Total Billed Charges","neg_dollar:$6037.96","3412.76","52","","","Percent of Total Billed Charges","neg_dollar:$3412.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","3412.76","52","","","Percent of Total Billed Charges","neg_dollar:$3412.76;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","6563.00",""
"ANESTHESIA LOCAL MIN","","","40040001","CDM","370","RC","","Facility","Outpatient","","","4","3.20","4.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.44","86","","","Percent of Total Billed Charges","neg_dollar:$3.44","2.80","70","","","Percent of Total Billed Charges","neg_dollar:$2.80","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.34;102% of Medicaid interim rate","3.00","75","","","Percent of Total Billed Charges","neg_dollar:$3","3.44","86","","","Percent of Total Billed Charges","neg_dollar:$3.44","2.80","70","","","Percent of Total Billed Charges","neg_dollar:$2.80","2.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.28;103.5% of Medicaid interim rate","4.00","150","","","Percent of Total Billed Charges","neg_dollar:$6.18;150% of Medicaid interim rate","3.20","80","","","Percent of Total Billed Charges","neg_dollar:$3.20;Percent of Total Billed Charges","3.68","92","","","Percent of Total Billed Charges","neg_dollar:$3.68","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"ANESTHESIA BASE","","","40040002","CDM","370","RC","","Facility","Outpatient","","","879","703.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","755.93","86","","","Percent of Total Billed Charges","neg_dollar:$755.93","615.30","70","","","Percent of Total Billed Charges","neg_dollar:$615.30","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","516.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$516.41;102% of Medicaid interim rate","659.25","75","","","Percent of Total Billed Charges","neg_dollar:$659.25","755.93","86","","","Percent of Total Billed Charges","neg_dollar:$755.93","615.30","70","","","Percent of Total Billed Charges","neg_dollar:$615.30","501.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$501.03;103.5% of Medicaid interim rate","879.00","150","","","Percent of Total Billed Charges","neg_dollar:$1358.97;150% of Medicaid interim rate","703.20","80","","","Percent of Total Billed Charges","neg_dollar:$703.20;Percent of Total Billed Charges","808.68","92","","","Percent of Total Billed Charges","neg_dollar:$808.68","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","457.00","879.00",""
"ANESTHESIA MIN","","","40040003","CDM","370","RC","","Facility","Outpatient","","","4","3.20","4.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.44","86","","","Percent of Total Billed Charges","neg_dollar:$3.44","2.80","70","","","Percent of Total Billed Charges","neg_dollar:$2.80","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.34;102% of Medicaid interim rate","3.00","75","","","Percent of Total Billed Charges","neg_dollar:$3","3.44","86","","","Percent of Total Billed Charges","neg_dollar:$3.44","2.80","70","","","Percent of Total Billed Charges","neg_dollar:$2.80","2.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.28;103.5% of Medicaid interim rate","4.00","150","","","Percent of Total Billed Charges","neg_dollar:$6.18;150% of Medicaid interim rate","3.20","80","","","Percent of Total Billed Charges","neg_dollar:$3.20;Percent of Total Billed Charges","3.68","92","","","Percent of Total Billed Charges","neg_dollar:$3.68","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"ANESTHESIA LOCAL BASE","","","40040004","CDM","370","RC","","Facility","Outpatient","","","342","273.60","342.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","177.84","52","","","Percent of Total Billed Charges","neg_dollar:$177.84;101% Medicare Outpatient Cost to Charge Ratio of 52%","342.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","177.84","52","","","Percent of Total Billed Charges","neg_dollar:$177.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","177.84","52","","","Percent of Total Billed Charges","neg_dollar:$177.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","177.84","52","","","Percent of Total Billed Charges","neg_dollar:$177.84;102% Medicare Outpatient Cost to Charge Ratio of 52%","294.12","86","","","Percent of Total Billed Charges","neg_dollar:$294.12","239.39","70","","","Percent of Total Billed Charges","neg_dollar:$239.39","177.84","52","","","Percent of Total Billed Charges","neg_dollar:$177.84;105% Medicare Outpatient Cost to Charge Ratio of 52%","200.92","56.99","","","Percent of Total Billed Charges","neg_dollar:$200.92;102% of Medicaid interim rate","256.50","75","","","Percent of Total Billed Charges","neg_dollar:$256.50","294.12","86","","","Percent of Total Billed Charges","neg_dollar:$294.12","239.39","70","","","Percent of Total Billed Charges","neg_dollar:$239.39","194.93","56.99","","","Percent of Total Billed Charges","neg_dollar:$194.93;103.5% of Medicaid interim rate","342.00","150","","","Percent of Total Billed Charges","neg_dollar:$528.74;150% of Medicaid interim rate","273.60","80","","","Percent of Total Billed Charges","neg_dollar:$273.60;Percent of Total Billed Charges","314.64","92","","","Percent of Total Billed Charges","neg_dollar:$314.64","177.84","52","","","Percent of Total Billed Charges","neg_dollar:$177.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","177.84","52","","","Percent of Total Billed Charges","neg_dollar:$177.84;100% Medicare Outpatient Cost to Charge Ratio of 52%","177.00","342.00",""
"ANESTHESIA MAC BASE","","","40040005","CDM","370","RC","","Facility","Outpatient","","","615","492.00","615.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","319.80","52","","","Percent of Total Billed Charges","neg_dollar:$319.80;101% Medicare Outpatient Cost to Charge Ratio of 52%","615.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","319.80","52","","","Percent of Total Billed Charges","neg_dollar:$319.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","319.80","52","","","Percent of Total Billed Charges","neg_dollar:$319.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","319.80","52","","","Percent of Total Billed Charges","neg_dollar:$319.80;102% Medicare Outpatient Cost to Charge Ratio of 52%","528.90","86","","","Percent of Total Billed Charges","neg_dollar:$528.90","430.50","70","","","Percent of Total Billed Charges","neg_dollar:$430.50","319.80","52","","","Percent of Total Billed Charges","neg_dollar:$319.80;105% Medicare Outpatient Cost to Charge Ratio of 52%","361.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$361.31;102% of Medicaid interim rate","461.25","75","","","Percent of Total Billed Charges","neg_dollar:$461.25","528.90","86","","","Percent of Total Billed Charges","neg_dollar:$528.90","430.50","70","","","Percent of Total Billed Charges","neg_dollar:$430.50","350.54","56.99","","","Percent of Total Billed Charges","neg_dollar:$350.54;103.5% of Medicaid interim rate","615.00","150","","","Percent of Total Billed Charges","neg_dollar:$950.82;150% of Medicaid interim rate","492.00","80","","","Percent of Total Billed Charges","neg_dollar:$492;Percent of Total Billed Charges","565.80","92","","","Percent of Total Billed Charges","neg_dollar:$565.80","319.80","52","","","Percent of Total Billed Charges","neg_dollar:$319.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","319.80","52","","","Percent of Total Billed Charges","neg_dollar:$319.80;100% Medicare Outpatient Cost to Charge Ratio of 52%","319.00","615.00",""
"ANESTHESIA MAC MIN","","","40040006","CDM","370","RC","","Facility","Outpatient","","","4","3.20","4.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","4.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.44","86","","","Percent of Total Billed Charges","neg_dollar:$3.44","2.80","70","","","Percent of Total Billed Charges","neg_dollar:$2.80","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","2.34","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.34;102% of Medicaid interim rate","3.00","75","","","Percent of Total Billed Charges","neg_dollar:$3","3.44","86","","","Percent of Total Billed Charges","neg_dollar:$3.44","2.80","70","","","Percent of Total Billed Charges","neg_dollar:$2.80","2.28","56.99","","","Percent of Total Billed Charges","neg_dollar:$2.28;103.5% of Medicaid interim rate","4.00","150","","","Percent of Total Billed Charges","neg_dollar:$6.18;150% of Medicaid interim rate","3.20","80","","","Percent of Total Billed Charges","neg_dollar:$3.20;Percent of Total Billed Charges","3.68","92","","","Percent of Total Billed Charges","neg_dollar:$3.68","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.08","52","","","Percent of Total Billed Charges","neg_dollar:$2.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","2.00","4.00",""
"ANESTHESIA BASE INCIDENT TO RADIOLOGY","","","40040007","CDM","371","RC","","Facility","Outpatient","","","776","620.80","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;101% Medicare Outpatient Cost to Charge Ratio of 52%","776.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;102% Medicare Outpatient Cost to Charge Ratio of 52%","667.36","86","","","Percent of Total Billed Charges","neg_dollar:$667.36","543.19","70","","","Percent of Total Billed Charges","neg_dollar:$543.19","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;105% Medicare Outpatient Cost to Charge Ratio of 52%","455.89","56.99","","","Percent of Total Billed Charges","neg_dollar:$455.89;102% of Medicaid interim rate","582.00","75","","","Percent of Total Billed Charges","neg_dollar:$582","667.36","86","","","Percent of Total Billed Charges","neg_dollar:$667.36","543.19","70","","","Percent of Total Billed Charges","neg_dollar:$543.19","442.31","56.99","","","Percent of Total Billed Charges","neg_dollar:$442.31;103.5% of Medicaid interim rate","776.00","150","","","Percent of Total Billed Charges","neg_dollar:$1199.73;150% of Medicaid interim rate","620.80","80","","","Percent of Total Billed Charges","neg_dollar:$620.80;Percent of Total Billed Charges","713.92","92","","","Percent of Total Billed Charges","neg_dollar:$713.92","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","403.52","52","","","Percent of Total Billed Charges","neg_dollar:$403.52;100% Medicare Outpatient Cost to Charge Ratio of 52%","403.00","776.00",""
"ANESTHESIA MINUTE INCIDENT TO RADIOLOGY","","","40040008","CDM","371","RC","","Facility","Outpatient","","","7","5.60","7.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.02","86","","","Percent of Total Billed Charges","neg_dollar:$6.02","4.89","70","","","Percent of Total Billed Charges","neg_dollar:$4.89","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","4.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.11;102% of Medicaid interim rate","5.25","75","","","Percent of Total Billed Charges","neg_dollar:$5.25","6.02","86","","","Percent of Total Billed Charges","neg_dollar:$6.02","4.89","70","","","Percent of Total Billed Charges","neg_dollar:$4.89","3.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.98;103.5% of Medicaid interim rate","7.00","150","","","Percent of Total Billed Charges","neg_dollar:$10.82;150% of Medicaid interim rate","5.60","80","","","Percent of Total Billed Charges","neg_dollar:$5.60;Percent of Total Billed Charges","6.44","92","","","Percent of Total Billed Charges","neg_dollar:$6.44","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","7.00",""
"SPINAL ANESTHESIA BASE","","","40040020","CDM","370","RC","","Facility","Outpatient","","","416","332.80","416.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","416.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","357.76","86","","","Percent of Total Billed Charges","neg_dollar:$357.76","291.20","70","","","Percent of Total Billed Charges","neg_dollar:$291.20","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","244.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$244.39;102% of Medicaid interim rate","312.00","75","","","Percent of Total Billed Charges","neg_dollar:$312","357.76","86","","","Percent of Total Billed Charges","neg_dollar:$357.76","291.20","70","","","Percent of Total Billed Charges","neg_dollar:$291.20","237.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.11;103.5% of Medicaid interim rate","416.00","150","","","Percent of Total Billed Charges","neg_dollar:$643.15;150% of Medicaid interim rate","332.80","80","","","Percent of Total Billed Charges","neg_dollar:$332.80;Percent of Total Billed Charges","382.72","92","","","Percent of Total Billed Charges","neg_dollar:$382.72","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","216.00","416.00",""
"ANESTHESIA EPIDURAL BASE","","","40040024","CDM","370","RC","","Facility","Outpatient","","","416","332.80","416.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;101% Medicare Outpatient Cost to Charge Ratio of 52%","416.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;102% Medicare Outpatient Cost to Charge Ratio of 52%","357.76","86","","","Percent of Total Billed Charges","neg_dollar:$357.76","291.20","70","","","Percent of Total Billed Charges","neg_dollar:$291.20","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;105% Medicare Outpatient Cost to Charge Ratio of 52%","244.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$244.39;102% of Medicaid interim rate","312.00","75","","","Percent of Total Billed Charges","neg_dollar:$312","357.76","86","","","Percent of Total Billed Charges","neg_dollar:$357.76","291.20","70","","","Percent of Total Billed Charges","neg_dollar:$291.20","237.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$237.11;103.5% of Medicaid interim rate","416.00","150","","","Percent of Total Billed Charges","neg_dollar:$643.15;150% of Medicaid interim rate","332.80","80","","","Percent of Total Billed Charges","neg_dollar:$332.80;Percent of Total Billed Charges","382.72","92","","","Percent of Total Billed Charges","neg_dollar:$382.72","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","216.32","52","","","Percent of Total Billed Charges","neg_dollar:$216.32;100% Medicare Outpatient Cost to Charge Ratio of 52%","216.00","416.00",""
"ANESTHESIA EPIDURAL MIN","","","40040025","CDM","370","RC","","Facility","Outpatient","","","7","5.60","7.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","7.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","6.02","86","","","Percent of Total Billed Charges","neg_dollar:$6.02","4.89","70","","","Percent of Total Billed Charges","neg_dollar:$4.89","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","4.11","56.99","","","Percent of Total Billed Charges","neg_dollar:$4.11;102% of Medicaid interim rate","5.25","75","","","Percent of Total Billed Charges","neg_dollar:$5.25","6.02","86","","","Percent of Total Billed Charges","neg_dollar:$6.02","4.89","70","","","Percent of Total Billed Charges","neg_dollar:$4.89","3.98","56.99","","","Percent of Total Billed Charges","neg_dollar:$3.98;103.5% of Medicaid interim rate","7.00","150","","","Percent of Total Billed Charges","neg_dollar:$10.82;150% of Medicaid interim rate","5.60","80","","","Percent of Total Billed Charges","neg_dollar:$5.60;Percent of Total Billed Charges","6.44","92","","","Percent of Total Billed Charges","neg_dollar:$6.44","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.64","52","","","Percent of Total Billed Charges","neg_dollar:$3.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","3.00","7.00",""
"MINOR PROCEDURE","","","60060006","CDM","761","RC","","Facility","Outpatient","","","882","705.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","758.52","86","","","Percent of Total Billed Charges","neg_dollar:$758.52","617.40","70","","","Percent of Total Billed Charges","neg_dollar:$617.40","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","518.17","56.99","","","Percent of Total Billed Charges","neg_dollar:$518.17;102% of Medicaid interim rate","661.50","75","","","Percent of Total Billed Charges","neg_dollar:$661.50","758.52","86","","","Percent of Total Billed Charges","neg_dollar:$758.52","617.40","70","","","Percent of Total Billed Charges","neg_dollar:$617.40","502.73","56.99","","","Percent of Total Billed Charges","neg_dollar:$502.73;103.5% of Medicaid interim rate","882.00","150","","","Percent of Total Billed Charges","neg_dollar:$1363.61;150% of Medicaid interim rate","705.60","80","","","Percent of Total Billed Charges","neg_dollar:$705.60;Percent of Total Billed Charges","811.44","92","","","Percent of Total Billed Charges","neg_dollar:$811.44","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","458.64","52","","","Percent of Total Billed Charges","neg_dollar:$458.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","458.00","882.00",""
"CIRCUMCISION","","","60060062","CDM","723","RC","","Facility","Outpatient","","","860","688.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","505.24","56.99","","","Percent of Total Billed Charges","neg_dollar:$505.24;102% of Medicaid interim rate","645.00","75","","","Percent of Total Billed Charges","neg_dollar:$645","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","490.19","56.99","","","Percent of Total Billed Charges","neg_dollar:$490.19;103.5% of Medicaid interim rate","860.00","150","","","Percent of Total Billed Charges","neg_dollar:$1329.60;150% of Medicaid interim rate","688.00","80","","","Percent of Total Billed Charges","neg_dollar:$688;Percent of Total Billed Charges","791.20","92","","","Percent of Total Billed Charges","neg_dollar:$791.20","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","447.20","52","","","Percent of Total Billed Charges","neg_dollar:$447.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","447.00","860.00",""
"VAGINAL DELIVERY LEVEL 1","","","60060095","CDM","722","RC","","Facility","Outpatient","","","2957","2365.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;102% Medicare Outpatient Cost to Charge Ratio of 52%","2543.02","86","","","Percent of Total Billed Charges","neg_dollar:$2543.02","2069.90","70","","","Percent of Total Billed Charges","neg_dollar:$2069.90","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;105% Medicare Outpatient Cost to Charge Ratio of 52%","1737.23","56.99","","","Percent of Total Billed Charges","neg_dollar:$1737.23;102% of Medicaid interim rate","2217.75","75","","","Percent of Total Billed Charges","neg_dollar:$2217.75","2543.02","86","","","Percent of Total Billed Charges","neg_dollar:$2543.02","2069.90","70","","","Percent of Total Billed Charges","neg_dollar:$2069.90","1685.48","56.99","","","Percent of Total Billed Charges","neg_dollar:$1685.48;103.5% of Medicaid interim rate","2957.00","150","","","Percent of Total Billed Charges","neg_dollar:$4571.66;150% of Medicaid interim rate","2365.60","80","","","Percent of Total Billed Charges","neg_dollar:$2365.60;Percent of Total Billed Charges","2720.44","92","","","Percent of Total Billed Charges","neg_dollar:$2720.44","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","1537.64","52","","","Percent of Total Billed Charges","neg_dollar:$1537.64;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","2957.00",""
"VAGINAL DELIVERY LEVEL 2","","","60060096","CDM","722","RC","","Facility","Outpatient","","","4223","3378.40","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;102% Medicare Outpatient Cost to Charge Ratio of 52%","3631.77","86","","","Percent of Total Billed Charges","neg_dollar:$3631.77","2956.10","70","","","Percent of Total Billed Charges","neg_dollar:$2956.10","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;105% Medicare Outpatient Cost to Charge Ratio of 52%","2481.00","56.99","","","Percent of Total Billed Charges","neg_dollar:$2481;102% of Medicaid interim rate","3167.25","75","","","Percent of Total Billed Charges","neg_dollar:$3167.25","3631.77","86","","","Percent of Total Billed Charges","neg_dollar:$3631.77","2956.10","70","","","Percent of Total Billed Charges","neg_dollar:$2956.10","2407.10","56.99","","","Percent of Total Billed Charges","neg_dollar:$2407.10;103.5% of Medicaid interim rate","4223.00","150","","","Percent of Total Billed Charges","neg_dollar:$6528.96;150% of Medicaid interim rate","3378.40","80","","","Percent of Total Billed Charges","neg_dollar:$3378.40;Percent of Total Billed Charges","3885.16","92","","","Percent of Total Billed Charges","neg_dollar:$3885.16","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","2195.96","52","","","Percent of Total Billed Charges","neg_dollar:$2195.96;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4223.00",""
"VAGINAL DELIVERY LEVEL 3","","","60060097","CDM","722","RC","","Facility","Outpatient","","","4927","3941.60","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","2562.04","52","","","Percent of Total Billed Charges","neg_dollar:$2562.04;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","2562.04","52","","","Percent of Total Billed Charges","neg_dollar:$2562.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2562.04","52","","","Percent of Total Billed Charges","neg_dollar:$2562.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","2562.04","52","","","Percent of Total Billed Charges","neg_dollar:$2562.04;102% Medicare Outpatient Cost to Charge Ratio of 52%","4237.22","86","","","Percent of Total Billed Charges","neg_dollar:$4237.22","3448.89","70","","","Percent of Total Billed Charges","neg_dollar:$3448.89","2562.04","52","","","Percent of Total Billed Charges","neg_dollar:$2562.04;105% Medicare Outpatient Cost to Charge Ratio of 52%","2894.60","56.99","","","Percent of Total Billed Charges","neg_dollar:$2894.60;102% of Medicaid interim rate","3695.25","75","","","Percent of Total Billed Charges","neg_dollar:$3695.25","4237.22","86","","","Percent of Total Billed Charges","neg_dollar:$4237.22","3448.89","70","","","Percent of Total Billed Charges","neg_dollar:$3448.89","2808.39","56.99","","","Percent of Total Billed Charges","neg_dollar:$2808.39;103.5% of Medicaid interim rate","4927.00","150","","","Percent of Total Billed Charges","neg_dollar:$7617.38;150% of Medicaid interim rate","3941.60","80","","","Percent of Total Billed Charges","neg_dollar:$3941.60;Percent of Total Billed Charges","4532.84","92","","","Percent of Total Billed Charges","neg_dollar:$4532.84","2562.04","52","","","Percent of Total Billed Charges","neg_dollar:$2562.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","2562.04","52","","","Percent of Total Billed Charges","neg_dollar:$2562.04;100% Medicare Outpatient Cost to Charge Ratio of 52%","747.00","4927.00",""
"AMBULATORY CARE CLASS I","","","70070001","CDM","710","RC","","Facility","Outpatient","","","185","148.00","185.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","96.20","52","","","Percent of Total Billed Charges","neg_dollar:$96.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","185.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","96.20","52","","","Percent of Total Billed Charges","neg_dollar:$96.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","96.20","52","","","Percent of Total Billed Charges","neg_dollar:$96.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","96.20","52","","","Percent of Total Billed Charges","neg_dollar:$96.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","159.10","86","","","Percent of Total Billed Charges","neg_dollar:$159.10","129.50","70","","","Percent of Total Billed Charges","neg_dollar:$129.50","96.20","52","","","Percent of Total Billed Charges","neg_dollar:$96.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","108.68","56.99","","","Percent of Total Billed Charges","neg_dollar:$108.68;102% of Medicaid interim rate","138.75","75","","","Percent of Total Billed Charges","neg_dollar:$138.75","159.10","86","","","Percent of Total Billed Charges","neg_dollar:$159.10","129.50","70","","","Percent of Total Billed Charges","neg_dollar:$129.50","105.44","56.99","","","Percent of Total Billed Charges","neg_dollar:$105.44;103.5% of Medicaid interim rate","185.00","150","","","Percent of Total Billed Charges","neg_dollar:$286.01;150% of Medicaid interim rate","148.00","80","","","Percent of Total Billed Charges","neg_dollar:$148;Percent of Total Billed Charges","170.20","92","","","Percent of Total Billed Charges","neg_dollar:$170.20","96.20","52","","","Percent of Total Billed Charges","neg_dollar:$96.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","96.20","52","","","Percent of Total Billed Charges","neg_dollar:$96.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","96.00","185.00",""
"AMBULATORY CARE CLASS II","","","70070002","CDM","710","RC","","Facility","Outpatient","","","424","339.20","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;101% Medicare Outpatient Cost to Charge Ratio of 52%","424.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;102% Medicare Outpatient Cost to Charge Ratio of 52%","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;105% Medicare Outpatient Cost to Charge Ratio of 52%","249.09","56.99","","","Percent of Total Billed Charges","neg_dollar:$249.09;102% of Medicaid interim rate","318.00","75","","","Percent of Total Billed Charges","neg_dollar:$318","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","241.67","56.99","","","Percent of Total Billed Charges","neg_dollar:$241.67;103.5% of Medicaid interim rate","424.00","150","","","Percent of Total Billed Charges","neg_dollar:$655.52;150% of Medicaid interim rate","339.20","80","","","Percent of Total Billed Charges","neg_dollar:$339.20;Percent of Total Billed Charges","390.08","92","","","Percent of Total Billed Charges","neg_dollar:$390.08","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.48","52","","","Percent of Total Billed Charges","neg_dollar:$220.48;100% Medicare Outpatient Cost to Charge Ratio of 52%","220.00","424.00",""
"AMBULATORY CARE CLASS III","","","70070003","CDM","710","RC","","Facility","Outpatient","","","705","564.00","705.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;101% Medicare Outpatient Cost to Charge Ratio of 52%","705.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;102% Medicare Outpatient Cost to Charge Ratio of 52%","606.30","86","","","Percent of Total Billed Charges","neg_dollar:$606.30","493.49","70","","","Percent of Total Billed Charges","neg_dollar:$493.49","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;105% Medicare Outpatient Cost to Charge Ratio of 52%","414.18","56.99","","","Percent of Total Billed Charges","neg_dollar:$414.18;102% of Medicaid interim rate","528.75","75","","","Percent of Total Billed Charges","neg_dollar:$528.75","606.30","86","","","Percent of Total Billed Charges","neg_dollar:$606.30","493.49","70","","","Percent of Total Billed Charges","neg_dollar:$493.49","401.84","56.99","","","Percent of Total Billed Charges","neg_dollar:$401.84;103.5% of Medicaid interim rate","705.00","150","","","Percent of Total Billed Charges","neg_dollar:$1089.96;150% of Medicaid interim rate","564.00","80","","","Percent of Total Billed Charges","neg_dollar:$564;Percent of Total Billed Charges","648.60","92","","","Percent of Total Billed Charges","neg_dollar:$648.60","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.60","52","","","Percent of Total Billed Charges","neg_dollar:$366.60;100% Medicare Outpatient Cost to Charge Ratio of 52%","366.00","705.00",""
"AMBULATORY CARE CLASS IV","","","70070004","CDM","710","RC","","Facility","Outpatient","","","810","648.00","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","421.20","52","","","Percent of Total Billed Charges","neg_dollar:$421.20;101% Medicare Outpatient Cost to Charge Ratio of 52%","810.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","421.20","52","","","Percent of Total Billed Charges","neg_dollar:$421.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","421.20","52","","","Percent of Total Billed Charges","neg_dollar:$421.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","421.20","52","","","Percent of Total Billed Charges","neg_dollar:$421.20;102% Medicare Outpatient Cost to Charge Ratio of 52%","696.60","86","","","Percent of Total Billed Charges","neg_dollar:$696.60","567.00","70","","","Percent of Total Billed Charges","neg_dollar:$567","421.20","52","","","Percent of Total Billed Charges","neg_dollar:$421.20;105% Medicare Outpatient Cost to Charge Ratio of 52%","475.87","56.99","","","Percent of Total Billed Charges","neg_dollar:$475.87;102% of Medicaid interim rate","607.50","75","","","Percent of Total Billed Charges","neg_dollar:$607.50","696.60","86","","","Percent of Total Billed Charges","neg_dollar:$696.60","567.00","70","","","Percent of Total Billed Charges","neg_dollar:$567","461.70","56.99","","","Percent of Total Billed Charges","neg_dollar:$461.70;103.5% of Medicaid interim rate","810.00","150","","","Percent of Total Billed Charges","neg_dollar:$1252.30;150% of Medicaid interim rate","648.00","80","","","Percent of Total Billed Charges","neg_dollar:$648;Percent of Total Billed Charges","745.20","92","","","Percent of Total Billed Charges","neg_dollar:$745.20","421.20","52","","","Percent of Total Billed Charges","neg_dollar:$421.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","421.20","52","","","Percent of Total Billed Charges","neg_dollar:$421.20;100% Medicare Outpatient Cost to Charge Ratio of 52%","421.00","810.00",""
"AMBULATORY CARE CLASS V","","","70070005","CDM","710","RC","","Facility","Outpatient","","","879","703.20","747.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","821.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","755.93","86","","","Percent of Total Billed Charges","neg_dollar:$755.93","615.30","70","","","Percent of Total Billed Charges","neg_dollar:$615.30","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","516.41","56.99","","","Percent of Total Billed Charges","neg_dollar:$516.41;102% of Medicaid interim rate","659.25","75","","","Percent of Total Billed Charges","neg_dollar:$659.25","755.93","86","","","Percent of Total Billed Charges","neg_dollar:$755.93","615.30","70","","","Percent of Total Billed Charges","neg_dollar:$615.30","501.03","56.99","","","Percent of Total Billed Charges","neg_dollar:$501.03;103.5% of Medicaid interim rate","879.00","150","","","Percent of Total Billed Charges","neg_dollar:$1358.97;150% of Medicaid interim rate","703.20","80","","","Percent of Total Billed Charges","neg_dollar:$703.20;Percent of Total Billed Charges","808.68","92","","","Percent of Total Billed Charges","neg_dollar:$808.68","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","457.08","52","","","Percent of Total Billed Charges","neg_dollar:$457.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","457.00","879.00",""
"PACU CLASS 1 PER MIN","","","70070006","CDM","710","RC","","Facility","Outpatient","","","18","14.40","18.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","9.36","52","","","Percent of Total Billed Charges","neg_dollar:$9.36;101% Medicare Outpatient Cost to Charge Ratio of 52%","18.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","9.36","52","","","Percent of Total Billed Charges","neg_dollar:$9.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.36","52","","","Percent of Total Billed Charges","neg_dollar:$9.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.36","52","","","Percent of Total Billed Charges","neg_dollar:$9.36;102% Medicare Outpatient Cost to Charge Ratio of 52%","15.48","86","","","Percent of Total Billed Charges","neg_dollar:$15.48","12.60","70","","","Percent of Total Billed Charges","neg_dollar:$12.60","9.36","52","","","Percent of Total Billed Charges","neg_dollar:$9.36;105% Medicare Outpatient Cost to Charge Ratio of 52%","10.57","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.57;102% of Medicaid interim rate","13.50","75","","","Percent of Total Billed Charges","neg_dollar:$13.50","15.48","86","","","Percent of Total Billed Charges","neg_dollar:$15.48","12.60","70","","","Percent of Total Billed Charges","neg_dollar:$12.60","10.26","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.26;103.5% of Medicaid interim rate","18.00","150","","","Percent of Total Billed Charges","neg_dollar:$27.82;150% of Medicaid interim rate","14.40","80","","","Percent of Total Billed Charges","neg_dollar:$14.40;Percent of Total Billed Charges","16.56","92","","","Percent of Total Billed Charges","neg_dollar:$16.56","9.36","52","","","Percent of Total Billed Charges","neg_dollar:$9.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.36","52","","","Percent of Total Billed Charges","neg_dollar:$9.36;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","18.00",""
"PACU CLASS 2 PER MIN","","","70070007","CDM","710","RC","","Facility","Outpatient","","","19","15.20","19.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","19.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.34","86","","","Percent of Total Billed Charges","neg_dollar:$16.34","13.29","70","","","Percent of Total Billed Charges","neg_dollar:$13.29","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","11.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.16;102% of Medicaid interim rate","14.25","75","","","Percent of Total Billed Charges","neg_dollar:$14.25","16.34","86","","","Percent of Total Billed Charges","neg_dollar:$16.34","13.29","70","","","Percent of Total Billed Charges","neg_dollar:$13.29","10.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.82;103.5% of Medicaid interim rate","19.00","150","","","Percent of Total Billed Charges","neg_dollar:$29.37;150% of Medicaid interim rate","15.20","80","","","Percent of Total Billed Charges","neg_dollar:$15.20;Percent of Total Billed Charges","17.48","92","","","Percent of Total Billed Charges","neg_dollar:$17.48","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","19.00",""
"PACU CLASS 3 PER MIN","","","70070008","CDM","710","RC","","Facility","Outpatient","","","19","15.20","19.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;101% Medicare Outpatient Cost to Charge Ratio of 52%","19.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;102% Medicare Outpatient Cost to Charge Ratio of 52%","16.34","86","","","Percent of Total Billed Charges","neg_dollar:$16.34","13.29","70","","","Percent of Total Billed Charges","neg_dollar:$13.29","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;105% Medicare Outpatient Cost to Charge Ratio of 52%","11.16","56.99","","","Percent of Total Billed Charges","neg_dollar:$11.16;102% of Medicaid interim rate","14.25","75","","","Percent of Total Billed Charges","neg_dollar:$14.25","16.34","86","","","Percent of Total Billed Charges","neg_dollar:$16.34","13.29","70","","","Percent of Total Billed Charges","neg_dollar:$13.29","10.82","56.99","","","Percent of Total Billed Charges","neg_dollar:$10.82;103.5% of Medicaid interim rate","19.00","150","","","Percent of Total Billed Charges","neg_dollar:$29.37;150% of Medicaid interim rate","15.20","80","","","Percent of Total Billed Charges","neg_dollar:$15.20;Percent of Total Billed Charges","17.48","92","","","Percent of Total Billed Charges","neg_dollar:$17.48","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.88","52","","","Percent of Total Billed Charges","neg_dollar:$9.88;100% Medicare Outpatient Cost to Charge Ratio of 52%","9.00","19.00",""
"TREATMENT ROOM NO CPT/HCPCS I","","","99000063","CDM","510","RC","","Facility","Outpatient","","","54","43.20","54.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $747","28.08","52","","","Percent of Total Billed Charges","neg_dollar:$28.08;101% Medicare Outpatient Cost to Charge Ratio of 52%","54.00","","EAPG x Base Rate","","Other","Base Rate: HMO - $821","28.08","52","","","Percent of Total Billed Charges","neg_dollar:$28.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.08","52","","","Percent of Total Billed Charges","neg_dollar:$28.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","28.08","52","","","Percent of Total Billed Charges","neg_dollar:$28.08;102% Medicare Outpatient Cost to Charge Ratio of 52%","46.44","86","","","Percent of Total Billed Charges","neg_dollar:$46.44","37.80","70","","","Percent of Total Billed Charges","neg_dollar:$37.80","28.08","52","","","Percent of Total Billed Charges","neg_dollar:$28.08;105% Medicare Outpatient Cost to Charge Ratio of 52%","31.72","56.99","","","Percent of Total Billed Charges","neg_dollar:$31.72;102% of Medicaid interim rate","40.50","75","","","Percent of Total Billed Charges","neg_dollar:$40.50","46.44","86","","","Percent of Total Billed Charges","neg_dollar:$46.44","37.80","70","","","Percent of Total Billed Charges","neg_dollar:$37.80","30.77","56.99","","","Percent of Total Billed Charges","neg_dollar:$30.77;103.5% of Medicaid interim rate","54.00","150","","","Percent of Total Billed Charges","neg_dollar:$83.48;150% of Medicaid interim rate","43.20","80","","","Percent of Total Billed Charges","neg_dollar:$43.20;Percent of Total Billed Charges","49.68","92","","","Percent of Total Billed Charges","neg_dollar:$49.68","28.08","52","","","Percent of Total Billed Charges","neg_dollar:$28.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","28.08","52","","","Percent of Total Billed Charges","neg_dollar:$28.08;100% Medicare Outpatient Cost to Charge Ratio of 52%","28.00","54.00",""
"GUIDE CATH FLUID DRAINAGE","10030","CPT","10000223","CDM","360","RC","","Facility","Inpatient","","","1283","1026.40","859.61","67","","","Percent of Total Billed Charges","neg_dollar:$859.61","1283.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","859.61","67","","","Percent of Total Billed Charges","neg_dollar:$859.61","1283.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1283.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1283.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1103.37","86","","","Percent of Total Billed Charges","neg_dollar:$1103.37","898.09","70","","","Percent of Total Billed Charges","neg_dollar:$898.09","1283.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1283.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","962.25","75","","","Percent of Total Billed Charges","neg_dollar:$962.25","1103.37","86","","","Percent of Total Billed Charges","neg_dollar:$1103.37","898.09","70","","","Percent of Total Billed Charges","neg_dollar:$898.09","1283.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1283.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1026.40","80","","","Percent of Total Billed Charges","neg_dollar:$1026.40;Percent of Total Billed Charges","1180.36","92","","","Percent of Total Billed Charges","neg_dollar:$1180.36","1283.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1283.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","859.00","1283.00",""
"I&D ABSC SMPL OR SGL","10060","CPT","10000075","CDM","761","RC","","Facility","Inpatient","","","446","356.80","298.82","67","","","Percent of Total Billed Charges","neg_dollar:$298.82","446.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","298.82","67","","","Percent of Total Billed Charges","neg_dollar:$298.82","446.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","446.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","446.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","383.56","86","","","Percent of Total Billed Charges","neg_dollar:$383.56","312.20","70","","","Percent of Total Billed Charges","neg_dollar:$312.20","446.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","446.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","334.50","75","","","Percent of Total Billed Charges","neg_dollar:$334.50","383.56","86","","","Percent of Total Billed Charges","neg_dollar:$383.56","312.20","70","","","Percent of Total Billed Charges","neg_dollar:$312.20","446.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","446.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","356.80","80","","","Percent of Total Billed Charges","neg_dollar:$356.80;Percent of Total Billed Charges","410.32","92","","","Percent of Total Billed Charges","neg_dollar:$410.32","446.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","446.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","298.00","446.00",""
"I&D ABSC COMPL OR MULTI","10061","CPT","10000076","CDM","360","RC","","Facility","Inpatient","","","1259","1007.20","843.53","67","","","Percent of Total Billed Charges","neg_dollar:$843.53","1259.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","843.53","67","","","Percent of Total Billed Charges","neg_dollar:$843.53","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","1259.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1259.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","944.25","75","","","Percent of Total Billed Charges","neg_dollar:$944.25","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","1259.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1259.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1007.20","80","","","Percent of Total Billed Charges","neg_dollar:$1007.20;Percent of Total Billed Charges","1158.28","92","","","Percent of Total Billed Charges","neg_dollar:$1158.28","1259.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","843.00","1259.00",""
"I&D PILONID CYS SMPL","10080","CPT","10000002","CDM","360","RC","","Facility","Inpatient","","","2216","1772.80","1484.72","67","","","Percent of Total Billed Charges","neg_dollar:$1484.72","2216.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1484.72","67","","","Percent of Total Billed Charges","neg_dollar:$1484.72","2216.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2216.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2216.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1905.76","86","","","Percent of Total Billed Charges","neg_dollar:$1905.76","1551.19","70","","","Percent of Total Billed Charges","neg_dollar:$1551.19","2216.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2216.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1662.00","75","","","Percent of Total Billed Charges","neg_dollar:$1662","1905.76","86","","","Percent of Total Billed Charges","neg_dollar:$1905.76","1551.19","70","","","Percent of Total Billed Charges","neg_dollar:$1551.19","2216.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2216.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1772.80","80","","","Percent of Total Billed Charges","neg_dollar:$1772.80;Percent of Total Billed Charges","2038.72","92","","","Percent of Total Billed Charges","neg_dollar:$2038.72","2216.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2216.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1484.00","2216.00",""
"INC & REM FB SQ SMPL","10120","CPT","10000004","CDM","360","RC","","Facility","Inpatient","","","797","637.60","533.99","67","","","Percent of Total Billed Charges","neg_dollar:$533.99","797.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","533.99","67","","","Percent of Total Billed Charges","neg_dollar:$533.99","797.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","797.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","797.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","685.42","86","","","Percent of Total Billed Charges","neg_dollar:$685.42","557.90","70","","","Percent of Total Billed Charges","neg_dollar:$557.90","797.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","797.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","597.75","75","","","Percent of Total Billed Charges","neg_dollar:$597.75","685.42","86","","","Percent of Total Billed Charges","neg_dollar:$685.42","557.90","70","","","Percent of Total Billed Charges","neg_dollar:$557.90","797.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","797.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","637.60","80","","","Percent of Total Billed Charges","neg_dollar:$637.60;Percent of Total Billed Charges","733.24","92","","","Percent of Total Billed Charges","neg_dollar:$733.24","797.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","797.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","533.00","797.00",""
"I&D HEMATOMA","10140","CPT","10000077","CDM","360","RC","","Facility","Inpatient","","","3701","2960.80","2479.67","67","","","Percent of Total Billed Charges","neg_dollar:$2479.67","3701.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2479.67","67","","","Percent of Total Billed Charges","neg_dollar:$2479.67","3701.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3701.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3701.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3182.86","86","","","Percent of Total Billed Charges","neg_dollar:$3182.86","2590.70","70","","","Percent of Total Billed Charges","neg_dollar:$2590.70","3701.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","3701.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","2775.75","75","","","Percent of Total Billed Charges","neg_dollar:$2775.75","3182.86","86","","","Percent of Total Billed Charges","neg_dollar:$3182.86","2590.70","70","","","Percent of Total Billed Charges","neg_dollar:$2590.70","3701.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","3701.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","2960.80","80","","","Percent of Total Billed Charges","neg_dollar:$2960.80;Percent of Total Billed Charges","3404.92","92","","","Percent of Total Billed Charges","neg_dollar:$3404.92","3701.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3701.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2479.00","3701.00",""
"PUNCT ASP ABSC HEMAT CYST","10160","CPT","10000078","CDM","360","RC","","Facility","Inpatient","","","1259","1007.20","843.53","67","","","Percent of Total Billed Charges","neg_dollar:$843.53","1259.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","843.53","67","","","Percent of Total Billed Charges","neg_dollar:$843.53","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","1259.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1259.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","944.25","75","","","Percent of Total Billed Charges","neg_dollar:$944.25","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","1259.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1259.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1007.20","80","","","Percent of Total Billed Charges","neg_dollar:$1007.20;Percent of Total Billed Charges","1158.28","92","","","Percent of Total Billed Charges","neg_dollar:$1158.28","1259.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","843.00","1259.00",""
"I&D CPLX POSTOP WND INF","10180","CPT","10000079","CDM","360","RC","","Facility","Inpatient","","","6915","5532.00","4633.05","67","","","Percent of Total Billed Charges","neg_dollar:$4633.05","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","4633.05","67","","","Percent of Total Billed Charges","neg_dollar:$4633.05","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","5946.90","86","","","Percent of Total Billed Charges","neg_dollar:$5946.90","4840.50","70","","","Percent of Total Billed Charges","neg_dollar:$4840.50","4432.05","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","6915.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","5186.25","75","","","Percent of Total Billed Charges","neg_dollar:$5186.25","5946.90","86","","","Percent of Total Billed Charges","neg_dollar:$5946.90","4840.50","70","","","Percent of Total Billed Charges","neg_dollar:$4840.50","6915.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","6915.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","5532.00","80","","","Percent of Total Billed Charges","neg_dollar:$5532;Percent of Total Billed Charges","6361.80","92","","","Percent of Total Billed Charges","neg_dollar:$6361.80","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","6915.00",""
"DEBR EXZ/INF SKIN 10% BS","11000","CPT","10000089","CDM","360","RC","","Facility","Inpatient","","","213","170.40","142.71","67","","","Percent of Total Billed Charges","neg_dollar:$142.71","213.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","142.71","67","","","Percent of Total Billed Charges","neg_dollar:$142.71","213.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","213.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","213.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","183.18","86","","","Percent of Total Billed Charges","neg_dollar:$183.18","149.10","70","","","Percent of Total Billed Charges","neg_dollar:$149.10","213.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","213.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","159.75","75","","","Percent of Total Billed Charges","neg_dollar:$159.75","183.18","86","","","Percent of Total Billed Charges","neg_dollar:$183.18","149.10","70","","","Percent of Total Billed Charges","neg_dollar:$149.10","213.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","213.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","170.40","80","","","Percent of Total Billed Charges","neg_dollar:$170.40;Percent of Total Billed Charges","195.96","92","","","Percent of Total Billed Charges","neg_dollar:$195.96","213.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","213.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","142.00","213.00",""
"DBRDMT ECZ/INFCT SKN EA ADDL","11001","CPT","10000347","CDM","761","RC","","Facility","Inpatient","","","77","61.60","51.59","67","","","Percent of Total Billed Charges","neg_dollar:$51.59","77.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","51.59","67","","","Percent of Total Billed Charges","neg_dollar:$51.59","77.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","77.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","77.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","66.22","86","","","Percent of Total Billed Charges","neg_dollar:$66.22","53.90","70","","","Percent of Total Billed Charges","neg_dollar:$53.90","77.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","77.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","57.75","75","","","Percent of Total Billed Charges","neg_dollar:$57.75","66.22","86","","","Percent of Total Billed Charges","neg_dollar:$66.22","53.90","70","","","Percent of Total Billed Charges","neg_dollar:$53.90","77.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","77.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","61.60","80","","","Percent of Total Billed Charges","neg_dollar:$61.60;Percent of Total Billed Charges","70.84","92","","","Percent of Total Billed Charges","neg_dollar:$70.84","77.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","77.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","51.00","77.00",""
"DBRDMT SKIN XTRNL GENT&PER","11004","CPT","10000346","CDM","761","RC","","Facility","Inpatient","","","1791","1432.80","1199.97","67","","","Percent of Total Billed Charges","neg_dollar:$1199.97","1791.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1199.97","67","","","Percent of Total Billed Charges","neg_dollar:$1199.97","1791.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1791.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1791.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1540.26","86","","","Percent of Total Billed Charges","neg_dollar:$1540.26","1253.69","70","","","Percent of Total Billed Charges","neg_dollar:$1253.69","1791.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1791.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1343.25","75","","","Percent of Total Billed Charges","neg_dollar:$1343.25","1540.26","86","","","Percent of Total Billed Charges","neg_dollar:$1540.26","1253.69","70","","","Percent of Total Billed Charges","neg_dollar:$1253.69","1791.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1791.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1432.80","80","","","Percent of Total Billed Charges","neg_dollar:$1432.80;Percent of Total Billed Charges","1647.72","92","","","Percent of Total Billed Charges","neg_dollar:$1647.72","1791.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1791.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1199.00","1791.00",""
"DBRDMT SKIN ABDOMINAL WALL","11005","CPT","10000348","CDM","761","RC","","Facility","Inpatient","","","2441","1952.80","1635.47","67","","","Percent of Total Billed Charges","neg_dollar:$1635.47","2441.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1635.47","67","","","Percent of Total Billed Charges","neg_dollar:$1635.47","2441.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2441.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2441.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2099.25","86","","","Percent of Total Billed Charges","neg_dollar:$2099.25","1708.69","70","","","Percent of Total Billed Charges","neg_dollar:$1708.69","2441.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2441.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1830.75","75","","","Percent of Total Billed Charges","neg_dollar:$1830.75","2099.25","86","","","Percent of Total Billed Charges","neg_dollar:$2099.25","1708.69","70","","","Percent of Total Billed Charges","neg_dollar:$1708.69","2441.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2441.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1952.80","80","","","Percent of Total Billed Charges","neg_dollar:$1952.80;Percent of Total Billed Charges","2245.72","92","","","Percent of Total Billed Charges","neg_dollar:$2245.72","2441.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2441.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1635.00","2441.00",""
"DBRDMT SKIN XTRNL GENT PER","11006","CPT","10000349","CDM","761","RC","","Facility","Inpatient","","","2209","1767.20","1480.03","67","","","Percent of Total Billed Charges","neg_dollar:$1480.03","2209.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1480.03","67","","","Percent of Total Billed Charges","neg_dollar:$1480.03","2209.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2209.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2209.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1899.74","86","","","Percent of Total Billed Charges","neg_dollar:$1899.74","1546.30","70","","","Percent of Total Billed Charges","neg_dollar:$1546.30","2209.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2209.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1656.75","75","","","Percent of Total Billed Charges","neg_dollar:$1656.75","1899.74","86","","","Percent of Total Billed Charges","neg_dollar:$1899.74","1546.30","70","","","Percent of Total Billed Charges","neg_dollar:$1546.30","2209.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2209.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1767.20","80","","","Percent of Total Billed Charges","neg_dollar:$1767.20;Percent of Total Billed Charges","2032.28","92","","","Percent of Total Billed Charges","neg_dollar:$2032.28","2209.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2209.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1480.00","2209.00",""
"RMV PRSTC MTRL/MESH ABD WALL","11008","CPT","10000350","CDM","761","RC","","Facility","Inpatient","","","860","688.00","576.20","67","","","Percent of Total Billed Charges","neg_dollar:$576.20","860.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","576.20","67","","","Percent of Total Billed Charges","neg_dollar:$576.20","860.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","860.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","860.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","860.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","860.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","645.00","75","","","Percent of Total Billed Charges","neg_dollar:$645","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","860.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","860.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","688.00","80","","","Percent of Total Billed Charges","neg_dollar:$688;Percent of Total Billed Charges","791.20","92","","","Percent of Total Billed Charges","neg_dollar:$791.20","860.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","860.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","576.00","860.00",""
"DEBR W OPEN FX SKIN & SQ","11010","CPT","10000090","CDM","360","RC","","Facility","Inpatient","","","1709","1367.20","1145.03","67","","","Percent of Total Billed Charges","neg_dollar:$1145.03","1709.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1145.03","67","","","Percent of Total Billed Charges","neg_dollar:$1145.03","1709.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1709.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1709.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1469.74","86","","","Percent of Total Billed Charges","neg_dollar:$1469.74","1196.30","70","","","Percent of Total Billed Charges","neg_dollar:$1196.30","1709.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1709.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1281.75","75","","","Percent of Total Billed Charges","neg_dollar:$1281.75","1469.74","86","","","Percent of Total Billed Charges","neg_dollar:$1469.74","1196.30","70","","","Percent of Total Billed Charges","neg_dollar:$1196.30","1709.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1709.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1367.20","80","","","Percent of Total Billed Charges","neg_dollar:$1367.20;Percent of Total Billed Charges","1572.28","92","","","Percent of Total Billed Charges","neg_dollar:$1572.28","1709.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1709.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1145.00","1709.00",""
"DEBRIDE SKIN MUSC AT FX SITE","11011","CPT","10000227","CDM","450","RC","","Facility","Inpatient","","","1597","1277.60","1069.99","67","","","Percent of Total Billed Charges","neg_dollar:$1069.99","1597.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1069.99","67","","","Percent of Total Billed Charges","neg_dollar:$1069.99","1597.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1597.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1597.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1373.42","86","","","Percent of Total Billed Charges","neg_dollar:$1373.42","1117.89","70","","","Percent of Total Billed Charges","neg_dollar:$1117.89","1597.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1597.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1197.75","75","","","Percent of Total Billed Charges","neg_dollar:$1197.75","1373.42","86","","","Percent of Total Billed Charges","neg_dollar:$1373.42","1117.89","70","","","Percent of Total Billed Charges","neg_dollar:$1117.89","1597.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1597.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1277.60","80","","","Percent of Total Billed Charges","neg_dollar:$1277.60;Percent of Total Billed Charges","1469.24","92","","","Percent of Total Billed Charges","neg_dollar:$1469.24","1597.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1597.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1069.00","1597.00",""
"DEBR O FX SKIN TO BONE","11012","CPT","10000006","CDM","360","RC","","Facility","Inpatient","","","2689","2151.20","1801.63","67","","","Percent of Total Billed Charges","neg_dollar:$1801.63","2689.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1801.63","67","","","Percent of Total Billed Charges","neg_dollar:$1801.63","2689.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2689.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2689.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2312.54","86","","","Percent of Total Billed Charges","neg_dollar:$2312.54","1882.30","70","","","Percent of Total Billed Charges","neg_dollar:$1882.30","2689.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2689.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","2016.75","75","","","Percent of Total Billed Charges","neg_dollar:$2016.75","2312.54","86","","","Percent of Total Billed Charges","neg_dollar:$2312.54","1882.30","70","","","Percent of Total Billed Charges","neg_dollar:$1882.30","2689.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2689.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","2151.20","80","","","Percent of Total Billed Charges","neg_dollar:$2151.20;Percent of Total Billed Charges","2473.88","92","","","Percent of Total Billed Charges","neg_dollar:$2473.88","2689.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2689.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1801.00","2689.00",""
"DEBRIDE SKIN TO SQ TISSUE","11042","CPT","10000080","CDM","761","RC","","Facility","Inpatient","","","1259","1007.20","843.53","67","","","Percent of Total Billed Charges","neg_dollar:$843.53","1259.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","843.53","67","","","Percent of Total Billed Charges","neg_dollar:$843.53","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","1259.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1259.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","944.25","75","","","Percent of Total Billed Charges","neg_dollar:$944.25","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","1259.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1259.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1007.20","80","","","Percent of Total Billed Charges","neg_dollar:$1007.20;Percent of Total Billed Charges","1158.28","92","","","Percent of Total Billed Charges","neg_dollar:$1158.28","1259.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","843.00","1259.00",""
"DEBRIDE SKIN & MUSCLE","11043","CPT","10000008","CDM","761","RC","","Facility","Inpatient","","","1928","1542.40","1291.76","67","","","Percent of Total Billed Charges","neg_dollar:$1291.76","1928.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1291.76","67","","","Percent of Total Billed Charges","neg_dollar:$1291.76","1928.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1928.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1928.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1658.08","86","","","Percent of Total Billed Charges","neg_dollar:$1658.08","1349.60","70","","","Percent of Total Billed Charges","neg_dollar:$1349.60","1928.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1928.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1446.00","75","","","Percent of Total Billed Charges","neg_dollar:$1446","1658.08","86","","","Percent of Total Billed Charges","neg_dollar:$1658.08","1349.60","70","","","Percent of Total Billed Charges","neg_dollar:$1349.60","1928.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1928.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1542.40","80","","","Percent of Total Billed Charges","neg_dollar:$1542.40;Percent of Total Billed Charges","1773.76","92","","","Percent of Total Billed Charges","neg_dollar:$1773.76","1928.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1928.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1291.00","1928.00",""
"DEBRIDE SKIN & BONE","11044","CPT","10000009","CDM","761","RC","","Facility","Inpatient","","","4054","3243.20","2716.18","67","","","Percent of Total Billed Charges","neg_dollar:$2716.18","4054.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2716.18","67","","","Percent of Total Billed Charges","neg_dollar:$2716.18","4054.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4054.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4054.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3486.44","86","","","Percent of Total Billed Charges","neg_dollar:$3486.44","2837.79","70","","","Percent of Total Billed Charges","neg_dollar:$2837.79","4054.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4054.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3040.50","75","","","Percent of Total Billed Charges","neg_dollar:$3040.50","3486.44","86","","","Percent of Total Billed Charges","neg_dollar:$3486.44","2837.79","70","","","Percent of Total Billed Charges","neg_dollar:$2837.79","4054.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4054.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3243.20","80","","","Percent of Total Billed Charges","neg_dollar:$3243.20;Percent of Total Billed Charges","3729.68","92","","","Percent of Total Billed Charges","neg_dollar:$3729.68","4054.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4054.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2716.00","4054.00",""
"DEB SUBQ TISSUE ADD-ON","11045","CPT","10000010","CDM","761","RC","","Facility","Inpatient","","","1035","828.00","693.45","67","","","Percent of Total Billed Charges","neg_dollar:$693.45","1035.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","693.45","67","","","Percent of Total Billed Charges","neg_dollar:$693.45","1035.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1035.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1035.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","890.10","86","","","Percent of Total Billed Charges","neg_dollar:$890.10","724.50","70","","","Percent of Total Billed Charges","neg_dollar:$724.50","1035.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1035.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","776.25","75","","","Percent of Total Billed Charges","neg_dollar:$776.25","890.10","86","","","Percent of Total Billed Charges","neg_dollar:$890.10","724.50","70","","","Percent of Total Billed Charges","neg_dollar:$724.50","1035.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1035.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","828.00","80","","","Percent of Total Billed Charges","neg_dollar:$828;Percent of Total Billed Charges","952.20","92","","","Percent of Total Billed Charges","neg_dollar:$952.20","1035.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1035.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","693.00","1035.00",""
"DEB MUSC/FASCIA ADD-ON","11046","CPT","10000011","CDM","761","RC","","Facility","Inpatient","","","1072","857.60","718.24","67","","","Percent of Total Billed Charges","neg_dollar:$718.24","1072.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","718.24","67","","","Percent of Total Billed Charges","neg_dollar:$718.24","1072.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1072.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1072.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","921.92","86","","","Percent of Total Billed Charges","neg_dollar:$921.92","750.40","70","","","Percent of Total Billed Charges","neg_dollar:$750.40","1072.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1072.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","804.00","75","","","Percent of Total Billed Charges","neg_dollar:$804","921.92","86","","","Percent of Total Billed Charges","neg_dollar:$921.92","750.40","70","","","Percent of Total Billed Charges","neg_dollar:$750.40","1072.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1072.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","857.60","80","","","Percent of Total Billed Charges","neg_dollar:$857.60;Percent of Total Billed Charges","986.24","92","","","Percent of Total Billed Charges","neg_dollar:$986.24","1072.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1072.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","718.00","1072.00",""
"DEB BONE ADD-ON","11047","CPT","10000012","CDM","761","RC","","Facility","Inpatient","","","3251","2600.80","2178.17","67","","","Percent of Total Billed Charges","neg_dollar:$2178.17","3251.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2178.17","67","","","Percent of Total Billed Charges","neg_dollar:$2178.17","3251.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3251.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3251.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2795.86","86","","","Percent of Total Billed Charges","neg_dollar:$2795.86","2275.70","70","","","Percent of Total Billed Charges","neg_dollar:$2275.70","3251.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","3251.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","2438.25","75","","","Percent of Total Billed Charges","neg_dollar:$2438.25","2795.86","86","","","Percent of Total Billed Charges","neg_dollar:$2795.86","2275.70","70","","","Percent of Total Billed Charges","neg_dollar:$2275.70","3251.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","3251.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","2600.80","80","","","Percent of Total Billed Charges","neg_dollar:$2600.80;Percent of Total Billed Charges","2990.92","92","","","Percent of Total Billed Charges","neg_dollar:$2990.92","3251.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3251.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2178.00","3251.00",""
"SPL AVULSE NP SGL","11730","CPT","10000083","CDM","360","RC","","Facility","Inpatient","","","509","407.20","341.03","67","","","Percent of Total Billed Charges","neg_dollar:$341.03","509.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","341.03","67","","","Percent of Total Billed Charges","neg_dollar:$341.03","509.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","509.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","509.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","437.74","86","","","Percent of Total Billed Charges","neg_dollar:$437.74","356.29","70","","","Percent of Total Billed Charges","neg_dollar:$356.29","509.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","509.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","381.75","75","","","Percent of Total Billed Charges","neg_dollar:$381.75","437.74","86","","","Percent of Total Billed Charges","neg_dollar:$437.74","356.29","70","","","Percent of Total Billed Charges","neg_dollar:$356.29","509.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","509.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","407.20","80","","","Percent of Total Billed Charges","neg_dollar:$407.20;Percent of Total Billed Charges","468.28","92","","","Percent of Total Billed Charges","neg_dollar:$468.28","509.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","509.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","341.00","509.00",""
"EVAC SU HEMATOMA","11740","CPT","10000021","CDM","360","RC","","Facility","Inpatient","","","406","324.80","272.02","67","","","Percent of Total Billed Charges","neg_dollar:$272.02","406.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","272.02","67","","","Percent of Total Billed Charges","neg_dollar:$272.02","406.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","406.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","406.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","349.15","86","","","Percent of Total Billed Charges","neg_dollar:$349.15","284.20","70","","","Percent of Total Billed Charges","neg_dollar:$284.20","406.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","406.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","304.50","75","","","Percent of Total Billed Charges","neg_dollar:$304.50","349.15","86","","","Percent of Total Billed Charges","neg_dollar:$349.15","284.20","70","","","Percent of Total Billed Charges","neg_dollar:$284.20","406.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","406.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","324.80","80","","","Percent of Total Billed Charges","neg_dollar:$324.80;Percent of Total Billed Charges","373.52","92","","","Percent of Total Billed Charges","neg_dollar:$373.52","406.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","406.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","272.00","406.00",""
"REMOVAL OF NAIL BED","11750","CPT","10000022","CDM","360","RC","","Facility","Inpatient","","","1259","1007.20","843.53","67","","","Percent of Total Billed Charges","neg_dollar:$843.53","1259.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","843.53","67","","","Percent of Total Billed Charges","neg_dollar:$843.53","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","1259.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1259.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","944.25","75","","","Percent of Total Billed Charges","neg_dollar:$944.25","1082.74","86","","","Percent of Total Billed Charges","neg_dollar:$1082.74","881.30","70","","","Percent of Total Billed Charges","neg_dollar:$881.30","1259.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1259.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1007.20","80","","","Percent of Total Billed Charges","neg_dollar:$1007.20;Percent of Total Billed Charges","1158.28","92","","","Percent of Total Billed Charges","neg_dollar:$1158.28","1259.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1259.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","843.00","1259.00",""
"REPAIR NAIL BED","11760","CPT","10000023","CDM","360","RC","","Facility","Inpatient","","","459","367.20","307.53","67","","","Percent of Total Billed Charges","neg_dollar:$307.53","459.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","307.53","67","","","Percent of Total Billed Charges","neg_dollar:$307.53","459.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","459.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","459.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","394.74","86","","","Percent of Total Billed Charges","neg_dollar:$394.74","321.29","70","","","Percent of Total Billed Charges","neg_dollar:$321.29","459.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","459.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","344.25","75","","","Percent of Total Billed Charges","neg_dollar:$344.25","394.74","86","","","Percent of Total Billed Charges","neg_dollar:$394.74","321.29","70","","","Percent of Total Billed Charges","neg_dollar:$321.29","459.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","459.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","367.20","80","","","Percent of Total Billed Charges","neg_dollar:$367.20;Percent of Total Billed Charges","422.28","92","","","Percent of Total Billed Charges","neg_dollar:$422.28","459.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","459.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","307.00","459.00",""
"INJECTION INTO SKIN LESIONS=<7","11900","CPT","10000117","CDM","761","RC","","Facility","Inpatient","","","445","356.00","298.15","67","","","Percent of Total Billed Charges","neg_dollar:$298.15","445.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","298.15","67","","","Percent of Total Billed Charges","neg_dollar:$298.15","445.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","445.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","445.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","382.70","86","","","Percent of Total Billed Charges","neg_dollar:$382.70","311.50","70","","","Percent of Total Billed Charges","neg_dollar:$311.50","445.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","445.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","333.75","75","","","Percent of Total Billed Charges","neg_dollar:$333.75","382.70","86","","","Percent of Total Billed Charges","neg_dollar:$382.70","311.50","70","","","Percent of Total Billed Charges","neg_dollar:$311.50","445.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","445.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","356.00","80","","","Percent of Total Billed Charges","neg_dollar:$356;Percent of Total Billed Charges","409.40","92","","","Percent of Total Billed Charges","neg_dollar:$409.40","445.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","445.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","298.00","445.00",""
"SREP S/N/A/G/TR/E 2.5 CM/<","12001","CPT","10000025","CDM","360","RC","","Facility","Inpatient","","","293","234.40","196.31","67","","","Percent of Total Billed Charges","neg_dollar:$196.31","293.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","196.31","67","","","Percent of Total Billed Charges","neg_dollar:$196.31","293.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","293.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","293.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","251.98","86","","","Percent of Total Billed Charges","neg_dollar:$251.98","205.10","70","","","Percent of Total Billed Charges","neg_dollar:$205.10","293.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","293.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","219.75","75","","","Percent of Total Billed Charges","neg_dollar:$219.75","251.98","86","","","Percent of Total Billed Charges","neg_dollar:$251.98","205.10","70","","","Percent of Total Billed Charges","neg_dollar:$205.10","293.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","293.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","234.40","80","","","Percent of Total Billed Charges","neg_dollar:$234.40;Percent of Total Billed Charges","269.56","92","","","Percent of Total Billed Charges","neg_dollar:$269.56","293.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","293.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","196.00","293.00",""
"SREP S/N/A/G/TR/E 2.6-7.5 CM","12002","CPT","10000026","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"SREP S/N/A/G/TR/E 7.6-12.5 CM","12004","CPT","10000027","CDM","360","RC","","Facility","Inpatient","","","284","227.20","190.28","67","","","Percent of Total Billed Charges","neg_dollar:$190.28","284.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","190.28","67","","","Percent of Total Billed Charges","neg_dollar:$190.28","284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","284.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","284.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","213.00","75","","","Percent of Total Billed Charges","neg_dollar:$213","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","284.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","284.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","227.20","80","","","Percent of Total Billed Charges","neg_dollar:$227.20;Percent of Total Billed Charges","261.28","92","","","Percent of Total Billed Charges","neg_dollar:$261.28","284.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","284.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","190.00","284.00",""
"SREP S/N/A/G/TR/E 12.6-20.0 CM","12005","CPT","10000028","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"SREP S/N/A/G/TR/E 20.1-30.0 CM","12006","CPT","10000029","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"SREP F/E/N/L/MM 2.5 CM/<","12011","CPT","10000031","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"SREP F/E/N/L/MM 2.6-5.0 CM","12013","CPT","10000032","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"SREP F/E/N/L/MM 5.1-7.5 CM","12014","CPT","10000033","CDM","360","RC","","Facility","Inpatient","","","284","227.20","190.28","67","","","Percent of Total Billed Charges","neg_dollar:$190.28","284.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","190.28","67","","","Percent of Total Billed Charges","neg_dollar:$190.28","284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","284.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","284.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","213.00","75","","","Percent of Total Billed Charges","neg_dollar:$213","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","284.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","284.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","227.20","80","","","Percent of Total Billed Charges","neg_dollar:$227.20;Percent of Total Billed Charges","261.28","92","","","Percent of Total Billed Charges","neg_dollar:$261.28","284.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","284.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","190.00","284.00",""
"SREP F/E/N/L/MM 7.6-12.5 CM","12015","CPT","10000034","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"TX S WND DEHISC SMPL","12020","CPT","10000037","CDM","360","RC","","Facility","Inpatient","","","1602","1281.60","1073.34","67","","","Percent of Total Billed Charges","neg_dollar:$1073.34","1602.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1073.34","67","","","Percent of Total Billed Charges","neg_dollar:$1073.34","1602.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1602.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1602.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1377.72","86","","","Percent of Total Billed Charges","neg_dollar:$1377.72","1121.39","70","","","Percent of Total Billed Charges","neg_dollar:$1121.39","1602.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1602.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1201.50","75","","","Percent of Total Billed Charges","neg_dollar:$1201.50","1377.72","86","","","Percent of Total Billed Charges","neg_dollar:$1377.72","1121.39","70","","","Percent of Total Billed Charges","neg_dollar:$1121.39","1602.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1602.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1281.60","80","","","Percent of Total Billed Charges","neg_dollar:$1281.60;Percent of Total Billed Charges","1473.84","92","","","Percent of Total Billed Charges","neg_dollar:$1473.84","1602.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1602.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1073.00","1602.00",""
"INT REP S/A/T/EX 2.5 CM/<","12031","CPT","10000039","CDM","360","RC","","Facility","Inpatient","","","564","451.20","377.88","67","","","Percent of Total Billed Charges","neg_dollar:$377.88","564.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","377.88","67","","","Percent of Total Billed Charges","neg_dollar:$377.88","564.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","564.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","564.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","564.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","564.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","423.00","75","","","Percent of Total Billed Charges","neg_dollar:$423","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","564.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","564.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","451.20","80","","","Percent of Total Billed Charges","neg_dollar:$451.20;Percent of Total Billed Charges","518.88","92","","","Percent of Total Billed Charges","neg_dollar:$518.88","564.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","564.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","377.00","564.00",""
"INT REP S/A/T/EX 2.6-7.5 CM","12032","CPT","10000040","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"INT REP S/A/T/EX 7.6-12.5 CM","12034","CPT","10000041","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"INT REP S/A/T/EX 12.6-20.0 CM","12035","CPT","10000042","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"INT REP N/H/F/G 2.5 CM/<","12041","CPT","10000045","CDM","360","RC","","Facility","Inpatient","","","485","388.00","324.95","67","","","Percent of Total Billed Charges","neg_dollar:$324.95","485.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","324.95","67","","","Percent of Total Billed Charges","neg_dollar:$324.95","485.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","485.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","485.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","417.09","86","","","Percent of Total Billed Charges","neg_dollar:$417.09","339.50","70","","","Percent of Total Billed Charges","neg_dollar:$339.50","485.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","485.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","363.75","75","","","Percent of Total Billed Charges","neg_dollar:$363.75","417.09","86","","","Percent of Total Billed Charges","neg_dollar:$417.09","339.50","70","","","Percent of Total Billed Charges","neg_dollar:$339.50","485.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","485.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","388.00","80","","","Percent of Total Billed Charges","neg_dollar:$388;Percent of Total Billed Charges","446.20","92","","","Percent of Total Billed Charges","neg_dollar:$446.20","485.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","485.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","324.00","485.00",""
"INT REP N/H/F/G 2.6-7.5 CM","12042","CPT","10000046","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"INT REP N/H/F/G 7.6-12.5 CM","12044","CPT","10000047","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"INT REP F/E/N/L/MM 2.5 CM/<","12051","CPT","10000051","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"INT REP F/E/N/L/MM 2.6-5.0 CM","12052","CPT","10000052","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"INT REP F/E/N/L/MM 5.1-7.5 CM","12053","CPT","10000053","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"INT REP F/E/N/L/MM 7.6-12.5 CM","12054","CPT","10000054","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"INT REP F/E/N/L/MM 12.6-20.0 CM","12055","CPT","10000055","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"CREP S/A/L 2.6-7.5 CM","13121","CPT","10000059","CDM","360","RC","","Facility","Inpatient","","","867","693.60","580.89","67","","","Percent of Total Billed Charges","neg_dollar:$580.89","867.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","580.89","67","","","Percent of Total Billed Charges","neg_dollar:$580.89","867.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","867.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","867.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","745.62","86","","","Percent of Total Billed Charges","neg_dollar:$745.62","606.90","70","","","Percent of Total Billed Charges","neg_dollar:$606.90","867.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","867.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","650.25","75","","","Percent of Total Billed Charges","neg_dollar:$650.25","745.62","86","","","Percent of Total Billed Charges","neg_dollar:$745.62","606.90","70","","","Percent of Total Billed Charges","neg_dollar:$606.90","867.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","867.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","693.60","80","","","Percent of Total Billed Charges","neg_dollar:$693.60;Percent of Total Billed Charges","797.64","92","","","Percent of Total Billed Charges","neg_dollar:$797.64","867.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","867.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","580.00","867.00",""
"CREP F/G/H/F 1.1-2.5 CM","13131","CPT","10000061","CDM","360","RC","","Facility","Inpatient","","","942","753.60","631.14","67","","","Percent of Total Billed Charges","neg_dollar:$631.14","942.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","631.14","67","","","Percent of Total Billed Charges","neg_dollar:$631.14","942.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","942.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","942.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","810.12","86","","","Percent of Total Billed Charges","neg_dollar:$810.12","659.40","70","","","Percent of Total Billed Charges","neg_dollar:$659.40","942.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","942.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","706.50","75","","","Percent of Total Billed Charges","neg_dollar:$706.50","810.12","86","","","Percent of Total Billed Charges","neg_dollar:$810.12","659.40","70","","","Percent of Total Billed Charges","neg_dollar:$659.40","942.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","942.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","753.60","80","","","Percent of Total Billed Charges","neg_dollar:$753.60;Percent of Total Billed Charges","866.64","92","","","Percent of Total Billed Charges","neg_dollar:$866.64","942.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","942.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","631.00","942.00",""
"CREP F/G/H/F 2.6-7.5 CM","13132","CPT","10000062","CDM","360","RC","","Facility","Inpatient","","","564","451.20","377.88","67","","","Percent of Total Billed Charges","neg_dollar:$377.88","564.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","377.88","67","","","Percent of Total Billed Charges","neg_dollar:$377.88","564.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","564.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","564.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","564.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","564.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","423.00","75","","","Percent of Total Billed Charges","neg_dollar:$423","485.04","86","","","Percent of Total Billed Charges","neg_dollar:$485.04","394.79","70","","","Percent of Total Billed Charges","neg_dollar:$394.79","564.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","564.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","451.20","80","","","Percent of Total Billed Charges","neg_dollar:$451.20;Percent of Total Billed Charges","518.88","92","","","Percent of Total Billed Charges","neg_dollar:$518.88","564.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","564.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","377.00","564.00",""
"CREP F/G/H/F EA ADD 5 CM/<","13133","CPT","10000063","CDM","360","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"CREP E/N/E/L 1.1-2.5 CM","13151","CPT","10000065","CDM","360","RC","","Facility","Inpatient","","","1098","878.40","735.66","67","","","Percent of Total Billed Charges","neg_dollar:$735.66","1098.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","735.66","67","","","Percent of Total Billed Charges","neg_dollar:$735.66","1098.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1098.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1098.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","944.28","86","","","Percent of Total Billed Charges","neg_dollar:$944.28","768.59","70","","","Percent of Total Billed Charges","neg_dollar:$768.59","1098.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1098.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","823.50","75","","","Percent of Total Billed Charges","neg_dollar:$823.50","944.28","86","","","Percent of Total Billed Charges","neg_dollar:$944.28","768.59","70","","","Percent of Total Billed Charges","neg_dollar:$768.59","1098.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1098.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","878.40","80","","","Percent of Total Billed Charges","neg_dollar:$878.40;Percent of Total Billed Charges","1010.16","92","","","Percent of Total Billed Charges","neg_dollar:$1010.16","1098.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1098.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","735.00","1098.00",""
"CREP E/N/E/L 2.6-7.5 CM","13152","CPT","10000066","CDM","360","RC","","Facility","Inpatient","","","1299","1039.20","870.33","67","","","Percent of Total Billed Charges","neg_dollar:$870.33","1299.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","870.33","67","","","Percent of Total Billed Charges","neg_dollar:$870.33","1299.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1299.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1299.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1117.13","86","","","Percent of Total Billed Charges","neg_dollar:$1117.13","909.30","70","","","Percent of Total Billed Charges","neg_dollar:$909.30","1299.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1299.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","974.25","75","","","Percent of Total Billed Charges","neg_dollar:$974.25","1117.13","86","","","Percent of Total Billed Charges","neg_dollar:$1117.13","909.30","70","","","Percent of Total Billed Charges","neg_dollar:$909.30","1299.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1299.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1039.20","80","","","Percent of Total Billed Charges","neg_dollar:$1039.20;Percent of Total Billed Charges","1195.08","92","","","Percent of Total Billed Charges","neg_dollar:$1195.08","1299.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1299.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","870.00","1299.00",""
"WOUND PREP TRNK/ARM/LEG 100 SQ CM/1% BA","15002","CPT","10000160","CDM","761","RC","","Facility","Inpatient","","","4712","3769.60","3157.04","67","","","Percent of Total Billed Charges","neg_dollar:$3157.04","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","3157.04","67","","","Percent of Total Billed Charges","neg_dollar:$3157.04","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4052.32","86","","","Percent of Total Billed Charges","neg_dollar:$4052.32","3298.39","70","","","Percent of Total Billed Charges","neg_dollar:$3298.39","4432.05","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4712.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3534.00","75","","","Percent of Total Billed Charges","neg_dollar:$3534","4052.32","86","","","Percent of Total Billed Charges","neg_dollar:$4052.32","3298.39","70","","","Percent of Total Billed Charges","neg_dollar:$3298.39","4712.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4712.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3769.60","80","","","Percent of Total Billed Charges","neg_dollar:$3769.60;Percent of Total Billed Charges","4335.04","92","","","Percent of Total Billed Charges","neg_dollar:$4335.04","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3157.00","4712.00",""
"WOUND PREP F/N/HF/G 100 SQ CM/1% BA","15004","CPT","10000068","CDM","761","RC","","Facility","Inpatient","","","1601","1280.80","1072.67","67","","","Percent of Total Billed Charges","neg_dollar:$1072.67","1601.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1072.67","67","","","Percent of Total Billed Charges","neg_dollar:$1072.67","1601.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1601.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1601.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1376.86","86","","","Percent of Total Billed Charges","neg_dollar:$1376.86","1120.69","70","","","Percent of Total Billed Charges","neg_dollar:$1120.69","1601.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1601.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1200.75","75","","","Percent of Total Billed Charges","neg_dollar:$1200.75","1376.86","86","","","Percent of Total Billed Charges","neg_dollar:$1376.86","1120.69","70","","","Percent of Total Billed Charges","neg_dollar:$1120.69","1601.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1601.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1280.80","80","","","Percent of Total Billed Charges","neg_dollar:$1280.80;Percent of Total Billed Charges","1472.92","92","","","Percent of Total Billed Charges","neg_dollar:$1472.92","1601.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1601.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1072.00","1601.00",""
"SKIN FULL GRFT FACE/GENIT/HF =< 20 SQ CM","15240","CPT","10000165","CDM","761","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"SKIN SUB GRAFT T/A/L 25 SQ CM","15271","CPT","10000130","CDM","761","RC","","Facility","Inpatient","","","4937","3949.60","3307.79","67","","","Percent of Total Billed Charges","neg_dollar:$3307.79","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","3307.79","67","","","Percent of Total Billed Charges","neg_dollar:$3307.79","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","4432.05","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4937.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3702.75","75","","","Percent of Total Billed Charges","neg_dollar:$3702.75","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","4937.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4937.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3949.60","80","","","Percent of Total Billed Charges","neg_dollar:$3949.60;Percent of Total Billed Charges","4542.04","92","","","Percent of Total Billed Charges","neg_dollar:$4542.04","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3307.00","4937.00",""
"SKIN SUB GRAFT T/A/L ADD 25 SQ CM","15272","CPT","10000131","CDM","761","RC","","Facility","Inpatient","","","4413","3530.40","2956.71","67","","","Percent of Total Billed Charges","neg_dollar:$2956.71","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2956.71","67","","","Percent of Total Billed Charges","neg_dollar:$2956.71","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","4413.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4413.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3309.75","75","","","Percent of Total Billed Charges","neg_dollar:$3309.75","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","4413.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4413.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3530.40","80","","","Percent of Total Billed Charges","neg_dollar:$3530.40;Percent of Total Billed Charges","4059.96","92","","","Percent of Total Billed Charges","neg_dollar:$4059.96","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2956.00","4413.00",""
"SKIN SUB GRFT T/A/L CHILD 100 SQ CM","15273","CPT","10000132","CDM","761","RC","","Facility","Inpatient","","","9610","7688.00","6438.70","67","","","Percent of Total Billed Charges","neg_dollar:$6438.70","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","6438.70","67","","","Percent of Total Billed Charges","neg_dollar:$6438.70","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","8264.60","86","","","Percent of Total Billed Charges","neg_dollar:$8264.60","6727.00","70","","","Percent of Total Billed Charges","neg_dollar:$6727","4432.05","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","9610.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","7207.50","75","","","Percent of Total Billed Charges","neg_dollar:$7207.50","8264.60","86","","","Percent of Total Billed Charges","neg_dollar:$8264.60","6727.00","70","","","Percent of Total Billed Charges","neg_dollar:$6727","9610.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","9610.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","7688.00","80","","","Percent of Total Billed Charges","neg_dollar:$7688;Percent of Total Billed Charges","8841.20","92","","","Percent of Total Billed Charges","neg_dollar:$8841.20","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","9610.00",""
"SKIN SUB GRFT T/A/L CH ADD 100 SQ CM","15274","CPT","10000133","CDM","761","RC","","Facility","Inpatient","","","9085","7268.00","6086.95","67","","","Percent of Total Billed Charges","neg_dollar:$6086.95","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","6086.95","67","","","Percent of Total Billed Charges","neg_dollar:$6086.95","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","7813.09","86","","","Percent of Total Billed Charges","neg_dollar:$7813.09","6359.50","70","","","Percent of Total Billed Charges","neg_dollar:$6359.50","4432.05","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","9085.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","6813.75","75","","","Percent of Total Billed Charges","neg_dollar:$6813.75","7813.09","86","","","Percent of Total Billed Charges","neg_dollar:$7813.09","6359.50","70","","","Percent of Total Billed Charges","neg_dollar:$6359.50","9085.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","9085.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","7268.00","80","","","Percent of Total Billed Charges","neg_dollar:$7268;Percent of Total Billed Charges","8358.20","92","","","Percent of Total Billed Charges","neg_dollar:$8358.20","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","9085.00",""
"SKIN SUB GRFT F/NK/HF/G 25 SQ CM","15275","CPT","10000134","CDM","761","RC","","Facility","Inpatient","","","4937","3949.60","3307.79","67","","","Percent of Total Billed Charges","neg_dollar:$3307.79","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","3307.79","67","","","Percent of Total Billed Charges","neg_dollar:$3307.79","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","4432.05","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4937.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3702.75","75","","","Percent of Total Billed Charges","neg_dollar:$3702.75","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","4937.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4937.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3949.60","80","","","Percent of Total Billed Charges","neg_dollar:$3949.60;Percent of Total Billed Charges","4542.04","92","","","Percent of Total Billed Charges","neg_dollar:$4542.04","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3307.00","4937.00",""
"SKIN SUB GRFT F/NK/HF/G ADD 25 SQ CM","15276","CPT","10000135","CDM","761","RC","","Facility","Inpatient","","","4413","3530.40","2956.71","67","","","Percent of Total Billed Charges","neg_dollar:$2956.71","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2956.71","67","","","Percent of Total Billed Charges","neg_dollar:$2956.71","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","4413.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4413.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3309.75","75","","","Percent of Total Billed Charges","neg_dollar:$3309.75","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","4413.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4413.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3530.40","80","","","Percent of Total Billed Charges","neg_dollar:$3530.40;Percent of Total Billed Charges","4059.96","92","","","Percent of Total Billed Charges","neg_dollar:$4059.96","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2956.00","4413.00",""
"SKN SUB GRFT F/NK/HF/G CHILD 100 SQ CM","15277","CPT","10000136","CDM","761","RC","","Facility","Inpatient","","","4937","3949.60","3307.79","67","","","Percent of Total Billed Charges","neg_dollar:$3307.79","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","3307.79","67","","","Percent of Total Billed Charges","neg_dollar:$3307.79","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","4432.05","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4937.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3702.75","75","","","Percent of Total Billed Charges","neg_dollar:$3702.75","4245.82","86","","","Percent of Total Billed Charges","neg_dollar:$4245.82","3455.89","70","","","Percent of Total Billed Charges","neg_dollar:$3455.89","4937.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4937.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3949.60","80","","","Percent of Total Billed Charges","neg_dollar:$3949.60;Percent of Total Billed Charges","4542.04","92","","","Percent of Total Billed Charges","neg_dollar:$4542.04","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3307.00","4937.00",""
"SKN SUB GRFT F/NK/HF/G CH ADD 100 SQ CM","15278","CPT","10000137","CDM","761","RC","","Facility","Inpatient","","","4413","3530.40","2956.71","67","","","Percent of Total Billed Charges","neg_dollar:$2956.71","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2956.71","67","","","Percent of Total Billed Charges","neg_dollar:$2956.71","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","4413.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4413.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3309.75","75","","","Percent of Total Billed Charges","neg_dollar:$3309.75","3795.18","86","","","Percent of Total Billed Charges","neg_dollar:$3795.18","3089.10","70","","","Percent of Total Billed Charges","neg_dollar:$3089.10","4413.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4413.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3530.40","80","","","Percent of Total Billed Charges","neg_dollar:$3530.40;Percent of Total Billed Charges","4059.96","92","","","Percent of Total Billed Charges","neg_dollar:$4059.96","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2956.00","4413.00",""
"DRESS/DEBRID P-THICK BURN M 5-10%","16025","CPT","10000086","CDM","360","RC","","Facility","Inpatient","","","440","352.00","294.80","67","","","Percent of Total Billed Charges","neg_dollar:$294.80","440.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","294.80","67","","","Percent of Total Billed Charges","neg_dollar:$294.80","440.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","440.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","440.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","378.40","86","","","Percent of Total Billed Charges","neg_dollar:$378.40","308.00","70","","","Percent of Total Billed Charges","neg_dollar:$308","440.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","440.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","330.00","75","","","Percent of Total Billed Charges","neg_dollar:$330","378.40","86","","","Percent of Total Billed Charges","neg_dollar:$378.40","308.00","70","","","Percent of Total Billed Charges","neg_dollar:$308","440.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","440.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","352.00","80","","","Percent of Total Billed Charges","neg_dollar:$352;Percent of Total Billed Charges","404.80","92","","","Percent of Total Billed Charges","neg_dollar:$404.80","440.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","440.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","294.00","440.00",""
"CHEM CAUT GRANULATION TISS","17250","CPT","10000088","CDM","761","RC","","Facility","Inpatient","","","354","283.20","237.18","67","","","Percent of Total Billed Charges","neg_dollar:$237.18","354.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","237.18","67","","","Percent of Total Billed Charges","neg_dollar:$237.18","354.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","354.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","354.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","304.44","86","","","Percent of Total Billed Charges","neg_dollar:$304.44","247.79","70","","","Percent of Total Billed Charges","neg_dollar:$247.79","354.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","354.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","265.50","75","","","Percent of Total Billed Charges","neg_dollar:$265.50","304.44","86","","","Percent of Total Billed Charges","neg_dollar:$304.44","247.79","70","","","Percent of Total Billed Charges","neg_dollar:$247.79","354.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","354.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","283.20","80","","","Percent of Total Billed Charges","neg_dollar:$283.20;Percent of Total Billed Charges","325.68","92","","","Percent of Total Billed Charges","neg_dollar:$325.68","354.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","354.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","237.00","354.00",""
"PUNCT ASP BREAST CYST INITIAL","19000","CPT","10000105","CDM","360","RC","","Facility","Inpatient","","","853","682.40","571.51","67","","","Percent of Total Billed Charges","neg_dollar:$571.51","853.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","571.51","67","","","Percent of Total Billed Charges","neg_dollar:$571.51","853.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","853.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","853.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","733.58","86","","","Percent of Total Billed Charges","neg_dollar:$733.58","597.09","70","","","Percent of Total Billed Charges","neg_dollar:$597.09","853.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","853.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","639.75","75","","","Percent of Total Billed Charges","neg_dollar:$639.75","733.58","86","","","Percent of Total Billed Charges","neg_dollar:$733.58","597.09","70","","","Percent of Total Billed Charges","neg_dollar:$597.09","853.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","853.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","682.40","80","","","Percent of Total Billed Charges","neg_dollar:$682.40;Percent of Total Billed Charges","784.76","92","","","Percent of Total Billed Charges","neg_dollar:$784.76","853.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","853.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","571.00","853.00",""
"PUNCT ASP BREAST CYST EA ADDTL","19001","CPT","10000106","CDM","360","RC","","Facility","Inpatient","","","333","266.40","223.11","67","","","Percent of Total Billed Charges","neg_dollar:$223.11","333.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","223.11","67","","","Percent of Total Billed Charges","neg_dollar:$223.11","333.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","333.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","333.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","286.38","86","","","Percent of Total Billed Charges","neg_dollar:$286.38","233.10","70","","","Percent of Total Billed Charges","neg_dollar:$233.10","333.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","333.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","249.75","75","","","Percent of Total Billed Charges","neg_dollar:$249.75","286.38","86","","","Percent of Total Billed Charges","neg_dollar:$286.38","233.10","70","","","Percent of Total Billed Charges","neg_dollar:$233.10","333.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","333.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","266.40","80","","","Percent of Total Billed Charges","neg_dollar:$266.40;Percent of Total Billed Charges","306.36","92","","","Percent of Total Billed Charges","neg_dollar:$306.36","333.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","333.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","223.00","333.00",""
"INJ MAMMARY DUCT","19030","CPT","10000107","CDM","360","RC","","Facility","Inpatient","","","431","344.80","288.77","67","","","Percent of Total Billed Charges","neg_dollar:$288.77","431.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","288.77","67","","","Percent of Total Billed Charges","neg_dollar:$288.77","431.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","431.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","431.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","370.65","86","","","Percent of Total Billed Charges","neg_dollar:$370.65","301.70","70","","","Percent of Total Billed Charges","neg_dollar:$301.70","431.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","431.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","323.25","75","","","Percent of Total Billed Charges","neg_dollar:$323.25","370.65","86","","","Percent of Total Billed Charges","neg_dollar:$370.65","301.70","70","","","Percent of Total Billed Charges","neg_dollar:$301.70","431.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","431.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","344.80","80","","","Percent of Total Billed Charges","neg_dollar:$344.80;Percent of Total Billed Charges","396.52","92","","","Percent of Total Billed Charges","neg_dollar:$396.52","431.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","431.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","288.00","431.00",""
"BX BREAST 1ST LESION STEREOTACTIC","19081","CPT","10000201","CDM","360","RC","","Facility","Inpatient","","","4644","3715.20","3111.48","67","","","Percent of Total Billed Charges","neg_dollar:$3111.48","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","3111.48","67","","","Percent of Total Billed Charges","neg_dollar:$3111.48","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3993.84","86","","","Percent of Total Billed Charges","neg_dollar:$3993.84","3250.79","70","","","Percent of Total Billed Charges","neg_dollar:$3250.79","4432.05","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4644.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3483.00","75","","","Percent of Total Billed Charges","neg_dollar:$3483","3993.84","86","","","Percent of Total Billed Charges","neg_dollar:$3993.84","3250.79","70","","","Percent of Total Billed Charges","neg_dollar:$3250.79","4644.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4644.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3715.20","80","","","Percent of Total Billed Charges","neg_dollar:$3715.20;Percent of Total Billed Charges","4272.48","92","","","Percent of Total Billed Charges","neg_dollar:$4272.48","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3111.00","4644.00",""
"BX BREAST ADD LESION STEREOTACTIC","19082","CPT","10000202","CDM","360","RC","","Facility","Inpatient","","","2555","2044.00","1711.85","67","","","Percent of Total Billed Charges","neg_dollar:$1711.85","2555.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1711.85","67","","","Percent of Total Billed Charges","neg_dollar:$1711.85","2555.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2555.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2555.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2197.30","86","","","Percent of Total Billed Charges","neg_dollar:$2197.30","1788.50","70","","","Percent of Total Billed Charges","neg_dollar:$1788.50","2555.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2555.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1916.25","75","","","Percent of Total Billed Charges","neg_dollar:$1916.25","2197.30","86","","","Percent of Total Billed Charges","neg_dollar:$2197.30","1788.50","70","","","Percent of Total Billed Charges","neg_dollar:$1788.50","2555.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2555.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","2044.00","80","","","Percent of Total Billed Charges","neg_dollar:$2044;Percent of Total Billed Charges","2350.60","92","","","Percent of Total Billed Charges","neg_dollar:$2350.60","2555.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2555.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1711.00","2555.00",""
"BX BREAST 1ST LESION US IMAG","19083","CPT","10000203","CDM","360","RC","","Facility","Inpatient","","","4644","3715.20","3111.48","67","","","Percent of Total Billed Charges","neg_dollar:$3111.48","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","3111.48","67","","","Percent of Total Billed Charges","neg_dollar:$3111.48","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3993.84","86","","","Percent of Total Billed Charges","neg_dollar:$3993.84","3250.79","70","","","Percent of Total Billed Charges","neg_dollar:$3250.79","4432.05","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4644.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3483.00","75","","","Percent of Total Billed Charges","neg_dollar:$3483","3993.84","86","","","Percent of Total Billed Charges","neg_dollar:$3993.84","3250.79","70","","","Percent of Total Billed Charges","neg_dollar:$3250.79","4644.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4644.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3715.20","80","","","Percent of Total Billed Charges","neg_dollar:$3715.20;Percent of Total Billed Charges","4272.48","92","","","Percent of Total Billed Charges","neg_dollar:$4272.48","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3111.00","4644.00",""
"BX BREAST ADD LESION US IMAG","19084","CPT","10000204","CDM","360","RC","","Facility","Inpatient","","","2555","2044.00","1711.85","67","","","Percent of Total Billed Charges","neg_dollar:$1711.85","2555.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1711.85","67","","","Percent of Total Billed Charges","neg_dollar:$1711.85","2555.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2555.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2555.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2197.30","86","","","Percent of Total Billed Charges","neg_dollar:$2197.30","1788.50","70","","","Percent of Total Billed Charges","neg_dollar:$1788.50","2555.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2555.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1916.25","75","","","Percent of Total Billed Charges","neg_dollar:$1916.25","2197.30","86","","","Percent of Total Billed Charges","neg_dollar:$2197.30","1788.50","70","","","Percent of Total Billed Charges","neg_dollar:$1788.50","2555.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2555.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","2044.00","80","","","Percent of Total Billed Charges","neg_dollar:$2044;Percent of Total Billed Charges","2350.60","92","","","Percent of Total Billed Charges","neg_dollar:$2350.60","2555.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2555.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1711.00","2555.00",""
"BX BREAST PERC NDL WO GUIDE","19100","CPT","10000108","CDM","360","RC","","Facility","Inpatient","","","1183","946.40","792.61","67","","","Percent of Total Billed Charges","neg_dollar:$792.61","1183.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","792.61","67","","","Percent of Total Billed Charges","neg_dollar:$792.61","1183.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1183.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1183.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1017.38","86","","","Percent of Total Billed Charges","neg_dollar:$1017.38","828.09","70","","","Percent of Total Billed Charges","neg_dollar:$828.09","1183.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1183.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","887.25","75","","","Percent of Total Billed Charges","neg_dollar:$887.25","1017.38","86","","","Percent of Total Billed Charges","neg_dollar:$1017.38","828.09","70","","","Percent of Total Billed Charges","neg_dollar:$828.09","1183.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1183.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","946.40","80","","","Percent of Total Billed Charges","neg_dollar:$946.40;Percent of Total Billed Charges","1088.36","92","","","Percent of Total Billed Charges","neg_dollar:$1088.36","1183.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1183.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","792.00","1183.00",""
"PERQ DEV BREAST 1ST LES MAMMO","19281","CPT","10000207","CDM","360","RC","","Facility","Inpatient","","","1578","1262.40","1057.26","67","","","Percent of Total Billed Charges","neg_dollar:$1057.26","1578.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1057.26","67","","","Percent of Total Billed Charges","neg_dollar:$1057.26","1578.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1578.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1578.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1357.08","86","","","Percent of Total Billed Charges","neg_dollar:$1357.08","1104.60","70","","","Percent of Total Billed Charges","neg_dollar:$1104.60","1578.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1578.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1183.50","75","","","Percent of Total Billed Charges","neg_dollar:$1183.50","1357.08","86","","","Percent of Total Billed Charges","neg_dollar:$1357.08","1104.60","70","","","Percent of Total Billed Charges","neg_dollar:$1104.60","1578.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1578.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1262.40","80","","","Percent of Total Billed Charges","neg_dollar:$1262.40;Percent of Total Billed Charges","1451.76","92","","","Percent of Total Billed Charges","neg_dollar:$1451.76","1578.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1578.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1057.00","1578.00",""
"PERQ DEV BREAST ADD LES MAMMO","19282","CPT","10000208","CDM","360","RC","","Facility","Inpatient","","","1283","1026.40","859.61","67","","","Percent of Total Billed Charges","neg_dollar:$859.61","1283.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","859.61","67","","","Percent of Total Billed Charges","neg_dollar:$859.61","1283.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1283.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1283.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1103.37","86","","","Percent of Total Billed Charges","neg_dollar:$1103.37","898.09","70","","","Percent of Total Billed Charges","neg_dollar:$898.09","1283.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1283.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","962.25","75","","","Percent of Total Billed Charges","neg_dollar:$962.25","1103.37","86","","","Percent of Total Billed Charges","neg_dollar:$1103.37","898.09","70","","","Percent of Total Billed Charges","neg_dollar:$898.09","1283.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1283.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1026.40","80","","","Percent of Total Billed Charges","neg_dollar:$1026.40;Percent of Total Billed Charges","1180.36","92","","","Percent of Total Billed Charges","neg_dollar:$1180.36","1283.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1283.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","859.00","1283.00",""
"PERQ DEV BREAST 1ST LES STEREOTACT","19283","CPT","10000209","CDM","360","RC","","Facility","Inpatient","","","1842","1473.60","1234.14","67","","","Percent of Total Billed Charges","neg_dollar:$1234.14","1842.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1234.14","67","","","Percent of Total Billed Charges","neg_dollar:$1234.14","1842.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1842.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1842.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1584.12","86","","","Percent of Total Billed Charges","neg_dollar:$1584.12","1289.39","70","","","Percent of Total Billed Charges","neg_dollar:$1289.39","1842.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1842.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1381.50","75","","","Percent of Total Billed Charges","neg_dollar:$1381.50","1584.12","86","","","Percent of Total Billed Charges","neg_dollar:$1584.12","1289.39","70","","","Percent of Total Billed Charges","neg_dollar:$1289.39","1842.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1842.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1473.60","80","","","Percent of Total Billed Charges","neg_dollar:$1473.60;Percent of Total Billed Charges","1694.64","92","","","Percent of Total Billed Charges","neg_dollar:$1694.64","1842.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1842.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1234.00","1842.00",""
"PERQ DEV BREAST ADD LES STEREOTACT","19284","CPT","10000210","CDM","360","RC","","Facility","Inpatient","","","761","608.80","509.87","67","","","Percent of Total Billed Charges","neg_dollar:$509.87","761.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","509.87","67","","","Percent of Total Billed Charges","neg_dollar:$509.87","761.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","761.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","761.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","654.46","86","","","Percent of Total Billed Charges","neg_dollar:$654.46","532.69","70","","","Percent of Total Billed Charges","neg_dollar:$532.69","761.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","761.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","570.75","75","","","Percent of Total Billed Charges","neg_dollar:$570.75","654.46","86","","","Percent of Total Billed Charges","neg_dollar:$654.46","532.69","70","","","Percent of Total Billed Charges","neg_dollar:$532.69","761.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","761.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","608.80","80","","","Percent of Total Billed Charges","neg_dollar:$608.80;Percent of Total Billed Charges","700.12","92","","","Percent of Total Billed Charges","neg_dollar:$700.12","761.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","761.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","509.00","761.00",""
"PERQ DEV BREAST 1ST LES US IMAG","19285","CPT","10000211","CDM","360","RC","","Facility","Inpatient","","","1536","1228.80","1029.12","67","","","Percent of Total Billed Charges","neg_dollar:$1029.12","1536.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1029.12","67","","","Percent of Total Billed Charges","neg_dollar:$1029.12","1536.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1536.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1536.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1320.96","86","","","Percent of Total Billed Charges","neg_dollar:$1320.96","1075.19","70","","","Percent of Total Billed Charges","neg_dollar:$1075.19","1536.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1536.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1152.00","75","","","Percent of Total Billed Charges","neg_dollar:$1152","1320.96","86","","","Percent of Total Billed Charges","neg_dollar:$1320.96","1075.19","70","","","Percent of Total Billed Charges","neg_dollar:$1075.19","1536.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1536.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1228.80","80","","","Percent of Total Billed Charges","neg_dollar:$1228.80;Percent of Total Billed Charges","1413.12","92","","","Percent of Total Billed Charges","neg_dollar:$1413.12","1536.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1536.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1029.00","1536.00",""
"PERQ DEV BREAST ADD LES US IMAG","19286","CPT","10000212","CDM","360","RC","","Facility","Inpatient","","","761","608.80","509.87","67","","","Percent of Total Billed Charges","neg_dollar:$509.87","761.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","509.87","67","","","Percent of Total Billed Charges","neg_dollar:$509.87","761.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","761.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","761.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","654.46","86","","","Percent of Total Billed Charges","neg_dollar:$654.46","532.69","70","","","Percent of Total Billed Charges","neg_dollar:$532.69","761.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","761.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","570.75","75","","","Percent of Total Billed Charges","neg_dollar:$570.75","654.46","86","","","Percent of Total Billed Charges","neg_dollar:$654.46","532.69","70","","","Percent of Total Billed Charges","neg_dollar:$532.69","761.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","761.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","608.80","80","","","Percent of Total Billed Charges","neg_dollar:$608.80;Percent of Total Billed Charges","700.12","92","","","Percent of Total Billed Charges","neg_dollar:$700.12","761.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","761.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","509.00","761.00",""
"INJ SINUS TRACT DIAGNOSTIC","20501","CPT","20000176","CDM","360","RC","","Facility","Inpatient","","","387","309.60","259.29","67","","","Percent of Total Billed Charges","neg_dollar:$259.29","387.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","259.29","67","","","Percent of Total Billed Charges","neg_dollar:$259.29","387.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","387.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","387.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","387.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","387.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","290.25","75","","","Percent of Total Billed Charges","neg_dollar:$290.25","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","387.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","387.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","309.60","80","","","Percent of Total Billed Charges","neg_dollar:$309.60;Percent of Total Billed Charges","356.04","92","","","Percent of Total Billed Charges","neg_dollar:$356.04","387.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","387.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","259.00","387.00",""
"INJ SGL TENDON SHTH OR LIGAMENT","20550","CPT","20000110","CDM","761","RC","","Facility","Inpatient","","","846","676.80","566.82","67","","","Percent of Total Billed Charges","neg_dollar:$566.82","846.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","566.82","67","","","Percent of Total Billed Charges","neg_dollar:$566.82","846.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","846.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","846.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","727.56","86","","","Percent of Total Billed Charges","neg_dollar:$727.56","592.19","70","","","Percent of Total Billed Charges","neg_dollar:$592.19","846.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","846.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","634.50","75","","","Percent of Total Billed Charges","neg_dollar:$634.50","727.56","86","","","Percent of Total Billed Charges","neg_dollar:$727.56","592.19","70","","","Percent of Total Billed Charges","neg_dollar:$592.19","846.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","846.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","676.80","80","","","Percent of Total Billed Charges","neg_dollar:$676.80;Percent of Total Billed Charges","778.32","92","","","Percent of Total Billed Charges","neg_dollar:$778.32","846.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","846.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","566.00","846.00",""
"INJ TRIGGER POINT 1/2 MUSCL","20552","CPT","20000111","CDM","761","RC","","Facility","Inpatient","","","847","677.60","567.49","67","","","Percent of Total Billed Charges","neg_dollar:$567.49","847.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","567.49","67","","","Percent of Total Billed Charges","neg_dollar:$567.49","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","847.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","847.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","847.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","847.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","779.24","92","","","Percent of Total Billed Charges","neg_dollar:$779.24","847.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","567.00","847.00",""
"INJECT TRIGGER POINTS=/>3","20553","CPT","20000004","CDM","761","RC","","Facility","Inpatient","","","847","677.60","567.49","67","","","Percent of Total Billed Charges","neg_dollar:$567.49","847.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","567.49","67","","","Percent of Total Billed Charges","neg_dollar:$567.49","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","847.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","847.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","847.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","847.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","779.24","92","","","Percent of Total Billed Charges","neg_dollar:$779.24","847.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","567.00","847.00",""
"NDL INSJ W/O NJX 1 OR 2 MUSC","20560","CPT","20000590","CDM","761","RC","","Facility","Inpatient","","","50","40.00","33.50","67","","","Percent of Total Billed Charges","neg_dollar:$33.50","50.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","33.50","67","","","Percent of Total Billed Charges","neg_dollar:$33.50","50.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","50.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","50.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","43.00","86","","","Percent of Total Billed Charges","neg_dollar:$43","35.00","70","","","Percent of Total Billed Charges","neg_dollar:$35","50.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","50.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","37.50","75","","","Percent of Total Billed Charges","neg_dollar:$37.50","43.00","86","","","Percent of Total Billed Charges","neg_dollar:$43","35.00","70","","","Percent of Total Billed Charges","neg_dollar:$35","50.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","50.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","40.00","80","","","Percent of Total Billed Charges","neg_dollar:$40;Percent of Total Billed Charges","46.00","92","","","Percent of Total Billed Charges","neg_dollar:$46","50.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","50.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","33.00","50.00",""
"NDL INSJ W/O NJX 3+ MUSC","20561","CPT","20000591","CDM","761","RC","","Facility","Inpatient","","","72","57.60","48.24","67","","","Percent of Total Billed Charges","neg_dollar:$48.24","72.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","48.24","67","","","Percent of Total Billed Charges","neg_dollar:$48.24","72.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","72.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","72.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","61.92","86","","","Percent of Total Billed Charges","neg_dollar:$61.92","50.40","70","","","Percent of Total Billed Charges","neg_dollar:$50.40","72.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","72.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","54.00","75","","","Percent of Total Billed Charges","neg_dollar:$54","61.92","86","","","Percent of Total Billed Charges","neg_dollar:$61.92","50.40","70","","","Percent of Total Billed Charges","neg_dollar:$50.40","72.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","72.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","57.60","80","","","Percent of Total Billed Charges","neg_dollar:$57.60;Percent of Total Billed Charges","66.24","92","","","Percent of Total Billed Charges","neg_dollar:$66.24","72.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","72.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","48.00","72.00",""
"DRAIN/INJ JOINT/BURSA W/O US","20600","CPT","20000112","CDM","360","RC","","Facility","Inpatient","","","847","677.60","567.49","67","","","Percent of Total Billed Charges","neg_dollar:$567.49","847.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","567.49","67","","","Percent of Total Billed Charges","neg_dollar:$567.49","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","847.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","847.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","847.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","847.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","779.24","92","","","Percent of Total Billed Charges","neg_dollar:$779.24","847.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","567.00","847.00",""
"DRAIN/INJ SMALL JOINT/BURSA W US","20604","CPT","20000355","CDM","761","RC","","Facility","Inpatient","","","750","600.00","502.50","67","","","Percent of Total Billed Charges","neg_dollar:$502.50","750.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","502.50","67","","","Percent of Total Billed Charges","neg_dollar:$502.50","750.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","750.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","750.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","645.00","86","","","Percent of Total Billed Charges","neg_dollar:$645","525.00","70","","","Percent of Total Billed Charges","neg_dollar:$525","750.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","750.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","562.50","75","","","Percent of Total Billed Charges","neg_dollar:$562.50","645.00","86","","","Percent of Total Billed Charges","neg_dollar:$645","525.00","70","","","Percent of Total Billed Charges","neg_dollar:$525","750.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","750.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","600.00","80","","","Percent of Total Billed Charges","neg_dollar:$600;Percent of Total Billed Charges","690.00","92","","","Percent of Total Billed Charges","neg_dollar:$690","750.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","750.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","502.00","750.00",""
"DRAIN/INJ INTERM JNT/BURSA","20605","CPT","20000113","CDM","761","RC","","Facility","Inpatient","","","847","677.60","567.49","67","","","Percent of Total Billed Charges","neg_dollar:$567.49","847.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","567.49","67","","","Percent of Total Billed Charges","neg_dollar:$567.49","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","847.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","847.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","847.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","847.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","779.24","92","","","Percent of Total Billed Charges","neg_dollar:$779.24","847.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","567.00","847.00",""
"DRAIN/INJ INTERM JNT/BURSA BILAT","20605","CPT","20000114","CDM","761","RC","50","Facility","Inpatient","","","1269","1015.20","850.23","67","","","Percent of Total Billed Charges","neg_dollar:$850.23","1269.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","850.23","67","","","Percent of Total Billed Charges","neg_dollar:$850.23","1269.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1269.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1269.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1091.34","86","","","Percent of Total Billed Charges","neg_dollar:$1091.34","888.30","70","","","Percent of Total Billed Charges","neg_dollar:$888.30","1269.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1269.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","951.75","75","","","Percent of Total Billed Charges","neg_dollar:$951.75","1091.34","86","","","Percent of Total Billed Charges","neg_dollar:$1091.34","888.30","70","","","Percent of Total Billed Charges","neg_dollar:$888.30","1269.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1269.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1015.20","80","","","Percent of Total Billed Charges","neg_dollar:$1015.20;Percent of Total Billed Charges","1167.48","92","","","Percent of Total Billed Charges","neg_dollar:$1167.48","1269.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1269.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","850.00","1269.00",""
"DRAIN/INJ INTERM JOINT/BURSA W US","20606","CPT","20000356","CDM","761","RC","","Facility","Inpatient","","","856","684.80","573.52","67","","","Percent of Total Billed Charges","neg_dollar:$573.52","856.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","573.52","67","","","Percent of Total Billed Charges","neg_dollar:$573.52","856.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","856.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","856.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","736.16","86","","","Percent of Total Billed Charges","neg_dollar:$736.16","599.19","70","","","Percent of Total Billed Charges","neg_dollar:$599.19","856.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","856.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","642.00","75","","","Percent of Total Billed Charges","neg_dollar:$642","736.16","86","","","Percent of Total Billed Charges","neg_dollar:$736.16","599.19","70","","","Percent of Total Billed Charges","neg_dollar:$599.19","856.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","856.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","684.80","80","","","Percent of Total Billed Charges","neg_dollar:$684.80;Percent of Total Billed Charges","787.52","92","","","Percent of Total Billed Charges","neg_dollar:$787.52","856.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","856.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","573.00","856.00",""
"DRAIN/INJ MAJOR JNT/BURSA","20610","CPT","20000115","CDM","761","RC","","Facility","Inpatient","","","847","677.60","567.49","67","","","Percent of Total Billed Charges","neg_dollar:$567.49","847.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","567.49","67","","","Percent of Total Billed Charges","neg_dollar:$567.49","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","847.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","847.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","635.25","75","","","Percent of Total Billed Charges","neg_dollar:$635.25","728.42","86","","","Percent of Total Billed Charges","neg_dollar:$728.42","592.90","70","","","Percent of Total Billed Charges","neg_dollar:$592.90","847.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","847.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","677.60","80","","","Percent of Total Billed Charges","neg_dollar:$677.60;Percent of Total Billed Charges","779.24","92","","","Percent of Total Billed Charges","neg_dollar:$779.24","847.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","847.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","567.00","847.00",""
"DRAIN/INJ MAJOR JNT/BURSA BILAT","20610","CPT","20000116","CDM","761","RC","50","Facility","Inpatient","","","1269","1015.20","850.23","67","","","Percent of Total Billed Charges","neg_dollar:$850.23","1269.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","850.23","67","","","Percent of Total Billed Charges","neg_dollar:$850.23","1269.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1269.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1269.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1091.34","86","","","Percent of Total Billed Charges","neg_dollar:$1091.34","888.30","70","","","Percent of Total Billed Charges","neg_dollar:$888.30","1269.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1269.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","951.75","75","","","Percent of Total Billed Charges","neg_dollar:$951.75","1091.34","86","","","Percent of Total Billed Charges","neg_dollar:$1091.34","888.30","70","","","Percent of Total Billed Charges","neg_dollar:$888.30","1269.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1269.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1015.20","80","","","Percent of Total Billed Charges","neg_dollar:$1015.20;Percent of Total Billed Charges","1167.48","92","","","Percent of Total Billed Charges","neg_dollar:$1167.48","1269.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1269.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","850.00","1269.00",""
"DRAIN/INJ MAJOR JOINT/BURSA W US","20611","CPT","20000357","CDM","761","RC","","Facility","Inpatient","","","469","375.20","314.23","67","","","Percent of Total Billed Charges","neg_dollar:$314.23","469.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","314.23","67","","","Percent of Total Billed Charges","neg_dollar:$314.23","469.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","469.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","469.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","403.34","86","","","Percent of Total Billed Charges","neg_dollar:$403.34","328.29","70","","","Percent of Total Billed Charges","neg_dollar:$328.29","469.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","469.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","351.75","75","","","Percent of Total Billed Charges","neg_dollar:$351.75","403.34","86","","","Percent of Total Billed Charges","neg_dollar:$403.34","328.29","70","","","Percent of Total Billed Charges","neg_dollar:$328.29","469.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","469.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","375.20","80","","","Percent of Total Billed Charges","neg_dollar:$375.20;Percent of Total Billed Charges","431.48","92","","","Percent of Total Billed Charges","neg_dollar:$431.48","469.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","469.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","314.00","469.00",""
"DRAIN/INJ MAJOR JOINT/BURSA W/US BILAT","20611","CPT","20000445","CDM","761","RC","50","Facility","Inpatient","","","705","564.00","472.35","67","","","Percent of Total Billed Charges","neg_dollar:$472.35","705.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","472.35","67","","","Percent of Total Billed Charges","neg_dollar:$472.35","705.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","705.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","705.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","606.30","86","","","Percent of Total Billed Charges","neg_dollar:$606.30","493.49","70","","","Percent of Total Billed Charges","neg_dollar:$493.49","705.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","705.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","528.75","75","","","Percent of Total Billed Charges","neg_dollar:$528.75","606.30","86","","","Percent of Total Billed Charges","neg_dollar:$606.30","493.49","70","","","Percent of Total Billed Charges","neg_dollar:$493.49","705.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","705.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","564.00","80","","","Percent of Total Billed Charges","neg_dollar:$564;Percent of Total Billed Charges","648.60","92","","","Percent of Total Billed Charges","neg_dollar:$648.60","705.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","705.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","472.00","705.00",""
"CL TX TMJ DISLOCATION INITIAL","21480","CPT","20000006","CDM","450","RC","","Facility","Inpatient","","","753","602.40","504.51","67","","","Percent of Total Billed Charges","neg_dollar:$504.51","753.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","504.51","67","","","Percent of Total Billed Charges","neg_dollar:$504.51","753.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","753.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","753.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","647.58","86","","","Percent of Total Billed Charges","neg_dollar:$647.58","527.10","70","","","Percent of Total Billed Charges","neg_dollar:$527.10","753.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","753.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","564.75","75","","","Percent of Total Billed Charges","neg_dollar:$564.75","647.58","86","","","Percent of Total Billed Charges","neg_dollar:$647.58","527.10","70","","","Percent of Total Billed Charges","neg_dollar:$527.10","753.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","753.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","602.40","80","","","Percent of Total Billed Charges","neg_dollar:$602.40;Percent of Total Billed Charges","692.76","92","","","Percent of Total Billed Charges","neg_dollar:$692.76","753.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","753.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","504.00","753.00",""
"INJ ARTHROGRAM SHOULDER","23350","CPT","20000187","CDM","360","RC","","Facility","Inpatient","","","261","208.80","174.87","67","","","Percent of Total Billed Charges","neg_dollar:$174.87","261.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","174.87","67","","","Percent of Total Billed Charges","neg_dollar:$174.87","261.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","261.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","261.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","224.46","86","","","Percent of Total Billed Charges","neg_dollar:$224.46","182.70","70","","","Percent of Total Billed Charges","neg_dollar:$182.70","261.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","261.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","195.75","75","","","Percent of Total Billed Charges","neg_dollar:$195.75","224.46","86","","","Percent of Total Billed Charges","neg_dollar:$224.46","182.70","70","","","Percent of Total Billed Charges","neg_dollar:$182.70","261.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","261.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","208.80","80","","","Percent of Total Billed Charges","neg_dollar:$208.80;Percent of Total Billed Charges","240.12","92","","","Percent of Total Billed Charges","neg_dollar:$240.12","261.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","261.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","174.00","261.00",""
"CL TX ACLAV DISLOC W MANIP","23545","CPT","20000132","CDM","450","RC","","Facility","Inpatient","","","1284","1027.20","860.28","67","","","Percent of Total Billed Charges","neg_dollar:$860.28","1284.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","860.28","67","","","Percent of Total Billed Charges","neg_dollar:$860.28","1284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1104.24","86","","","Percent of Total Billed Charges","neg_dollar:$1104.24","898.80","70","","","Percent of Total Billed Charges","neg_dollar:$898.80","1284.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1284.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","963.00","75","","","Percent of Total Billed Charges","neg_dollar:$963","1104.24","86","","","Percent of Total Billed Charges","neg_dollar:$1104.24","898.80","70","","","Percent of Total Billed Charges","neg_dollar:$898.80","1284.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1284.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1027.20","80","","","Percent of Total Billed Charges","neg_dollar:$1027.20;Percent of Total Billed Charges","1181.28","92","","","Percent of Total Billed Charges","neg_dollar:$1181.28","1284.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1284.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","860.00","1284.00",""
"CL TX SCAPULAR FX W MANIP","23575","CPT","20000318","CDM","450","RC","","Facility","Inpatient","","","1166","932.80","781.22","67","","","Percent of Total Billed Charges","neg_dollar:$781.22","1166.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","781.22","67","","","Percent of Total Billed Charges","neg_dollar:$781.22","1166.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1166.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1166.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1002.76","86","","","Percent of Total Billed Charges","neg_dollar:$1002.76","816.19","70","","","Percent of Total Billed Charges","neg_dollar:$816.19","1166.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1166.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","874.50","75","","","Percent of Total Billed Charges","neg_dollar:$874.50","1002.76","86","","","Percent of Total Billed Charges","neg_dollar:$1002.76","816.19","70","","","Percent of Total Billed Charges","neg_dollar:$816.19","1166.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1166.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","932.80","80","","","Percent of Total Billed Charges","neg_dollar:$932.80;Percent of Total Billed Charges","1072.72","92","","","Percent of Total Billed Charges","neg_dollar:$1072.72","1166.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1166.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","781.00","1166.00",""
"CL TX SHLDR DISL W MANI WO ANESTH","23650","CPT","20000016","CDM","450","RC","","Facility","Inpatient","","","674","539.20","451.58","67","","","Percent of Total Billed Charges","neg_dollar:$451.58","674.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","451.58","67","","","Percent of Total Billed Charges","neg_dollar:$451.58","674.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","674.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","674.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","579.64","86","","","Percent of Total Billed Charges","neg_dollar:$579.64","471.79","70","","","Percent of Total Billed Charges","neg_dollar:$471.79","674.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","674.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","505.50","75","","","Percent of Total Billed Charges","neg_dollar:$505.50","579.64","86","","","Percent of Total Billed Charges","neg_dollar:$579.64","471.79","70","","","Percent of Total Billed Charges","neg_dollar:$471.79","674.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","674.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","539.20","80","","","Percent of Total Billed Charges","neg_dollar:$539.20;Percent of Total Billed Charges","620.08","92","","","Percent of Total Billed Charges","neg_dollar:$620.08","674.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","674.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","451.00","674.00",""
"CL TX SHLDR DISL W MANIP W ANESTH","23655","CPT","20000134","CDM","450","RC","","Facility","Inpatient","","","2113","1690.40","1415.71","67","","","Percent of Total Billed Charges","neg_dollar:$1415.71","2113.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1415.71","67","","","Percent of Total Billed Charges","neg_dollar:$1415.71","2113.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2113.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2113.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1817.18","86","","","Percent of Total Billed Charges","neg_dollar:$1817.18","1479.10","70","","","Percent of Total Billed Charges","neg_dollar:$1479.10","2113.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2113.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1584.75","75","","","Percent of Total Billed Charges","neg_dollar:$1584.75","1817.18","86","","","Percent of Total Billed Charges","neg_dollar:$1817.18","1479.10","70","","","Percent of Total Billed Charges","neg_dollar:$1479.10","2113.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2113.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1690.40","80","","","Percent of Total Billed Charges","neg_dollar:$1690.40;Percent of Total Billed Charges","1943.96","92","","","Percent of Total Billed Charges","neg_dollar:$1943.96","2113.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2113.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1415.00","2113.00",""
"CL TX SHLDR DISLOC & FX GT W MANIP","23665","CPT","20000017","CDM","450","RC","","Facility","Inpatient","","","1391","1112.80","931.97","67","","","Percent of Total Billed Charges","neg_dollar:$931.97","1391.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","931.97","67","","","Percent of Total Billed Charges","neg_dollar:$931.97","1391.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1391.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1391.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1196.26","86","","","Percent of Total Billed Charges","neg_dollar:$1196.26","973.69","70","","","Percent of Total Billed Charges","neg_dollar:$973.69","1391.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1391.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1043.25","75","","","Percent of Total Billed Charges","neg_dollar:$1043.25","1196.26","86","","","Percent of Total Billed Charges","neg_dollar:$1196.26","973.69","70","","","Percent of Total Billed Charges","neg_dollar:$973.69","1391.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1391.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1112.80","80","","","Percent of Total Billed Charges","neg_dollar:$1112.80;Percent of Total Billed Charges","1279.72","92","","","Percent of Total Billed Charges","neg_dollar:$1279.72","1391.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1391.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","931.00","1391.00",""
"I&D BURSA UA/ELBOW","23931","CPT","20000226","CDM","360","RC","","Facility","Inpatient","","","1405","1124.00","941.35","67","","","Percent of Total Billed Charges","neg_dollar:$941.35","1405.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","941.35","67","","","Percent of Total Billed Charges","neg_dollar:$941.35","1405.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1405.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1405.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1208.30","86","","","Percent of Total Billed Charges","neg_dollar:$1208.30","983.49","70","","","Percent of Total Billed Charges","neg_dollar:$983.49","1405.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1405.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1053.75","75","","","Percent of Total Billed Charges","neg_dollar:$1053.75","1208.30","86","","","Percent of Total Billed Charges","neg_dollar:$1208.30","983.49","70","","","Percent of Total Billed Charges","neg_dollar:$983.49","1405.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1405.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1124.00","80","","","Percent of Total Billed Charges","neg_dollar:$1124;Percent of Total Billed Charges","1292.60","92","","","Percent of Total Billed Charges","neg_dollar:$1292.60","1405.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1405.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","941.00","1405.00",""
"TX CL ELBOW DISLOC WO ANESTH","24600","CPT","20000021","CDM","450","RC","","Facility","Inpatient","","","681","544.80","456.27","67","","","Percent of Total Billed Charges","neg_dollar:$456.27","681.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","456.27","67","","","Percent of Total Billed Charges","neg_dollar:$456.27","681.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","681.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","681.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","585.66","86","","","Percent of Total Billed Charges","neg_dollar:$585.66","476.70","70","","","Percent of Total Billed Charges","neg_dollar:$476.70","681.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","681.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","510.75","75","","","Percent of Total Billed Charges","neg_dollar:$510.75","585.66","86","","","Percent of Total Billed Charges","neg_dollar:$585.66","476.70","70","","","Percent of Total Billed Charges","neg_dollar:$476.70","681.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","681.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","544.80","80","","","Percent of Total Billed Charges","neg_dollar:$544.80;Percent of Total Billed Charges","626.52","92","","","Percent of Total Billed Charges","neg_dollar:$626.52","681.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","681.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","456.00","681.00",""
"TX CL ELBOW DISLOC W ANESTH","24605","CPT","20000195","CDM","450","RC","","Facility","Inpatient","","","1055","844.00","706.85","67","","","Percent of Total Billed Charges","neg_dollar:$706.85","1055.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","706.85","67","","","Percent of Total Billed Charges","neg_dollar:$706.85","1055.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1055.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1055.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","907.30","86","","","Percent of Total Billed Charges","neg_dollar:$907.30","738.50","70","","","Percent of Total Billed Charges","neg_dollar:$738.50","1055.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1055.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","791.25","75","","","Percent of Total Billed Charges","neg_dollar:$791.25","907.30","86","","","Percent of Total Billed Charges","neg_dollar:$907.30","738.50","70","","","Percent of Total Billed Charges","neg_dollar:$738.50","1055.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1055.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","844.00","80","","","Percent of Total Billed Charges","neg_dollar:$844;Percent of Total Billed Charges","970.60","92","","","Percent of Total Billed Charges","neg_dollar:$970.60","1055.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1055.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","706.00","1055.00",""
"CL TX NURSEMAID ELBOW W MANIP","24640","CPT","20000022","CDM","450","RC","","Facility","Inpatient","","","518","414.40","347.06","67","","","Percent of Total Billed Charges","neg_dollar:$347.06","518.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","347.06","67","","","Percent of Total Billed Charges","neg_dollar:$347.06","518.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","518.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","518.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","445.48","86","","","Percent of Total Billed Charges","neg_dollar:$445.48","362.59","70","","","Percent of Total Billed Charges","neg_dollar:$362.59","518.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","518.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","388.50","75","","","Percent of Total Billed Charges","neg_dollar:$388.50","445.48","86","","","Percent of Total Billed Charges","neg_dollar:$445.48","362.59","70","","","Percent of Total Billed Charges","neg_dollar:$362.59","518.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","518.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","414.40","80","","","Percent of Total Billed Charges","neg_dollar:$414.40;Percent of Total Billed Charges","476.56","92","","","Percent of Total Billed Charges","neg_dollar:$476.56","518.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","518.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","347.00","518.00",""
"INCISION OF TENDON SHEATH","25000","CPT","20000604","CDM","360","RC","","Facility","Inpatient","","","1712","1369.60","1147.04","67","","","Percent of Total Billed Charges","neg_dollar:$1147.04","1712.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1147.04","67","","","Percent of Total Billed Charges","neg_dollar:$1147.04","1712.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1712.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1712.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1472.32","86","","","Percent of Total Billed Charges","neg_dollar:$1472.32","1198.39","70","","","Percent of Total Billed Charges","neg_dollar:$1198.39","1712.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1712.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1284.00","75","","","Percent of Total Billed Charges","neg_dollar:$1284","1472.32","86","","","Percent of Total Billed Charges","neg_dollar:$1472.32","1198.39","70","","","Percent of Total Billed Charges","neg_dollar:$1198.39","1712.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1712.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1369.60","80","","","Percent of Total Billed Charges","neg_dollar:$1369.60;Percent of Total Billed Charges","1575.04","92","","","Percent of Total Billed Charges","neg_dollar:$1575.04","1712.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1712.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1147.00","1712.00",""
"TX FRACTURE D RADIUS/ULNA W MANIP","25605","CPT","20000033","CDM","450","RC","","Facility","Inpatient","","","917","733.60","614.39","67","","","Percent of Total Billed Charges","neg_dollar:$614.39","917.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","614.39","67","","","Percent of Total Billed Charges","neg_dollar:$614.39","917.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","917.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","917.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","788.62","86","","","Percent of Total Billed Charges","neg_dollar:$788.62","641.90","70","","","Percent of Total Billed Charges","neg_dollar:$641.90","917.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","917.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","687.75","75","","","Percent of Total Billed Charges","neg_dollar:$687.75","788.62","86","","","Percent of Total Billed Charges","neg_dollar:$788.62","641.90","70","","","Percent of Total Billed Charges","neg_dollar:$641.90","917.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","917.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","733.60","80","","","Percent of Total Billed Charges","neg_dollar:$733.60;Percent of Total Billed Charges","843.64","92","","","Percent of Total Billed Charges","neg_dollar:$843.64","917.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","917.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","614.00","917.00",""
"TX FX DISTAL RADIAL/EPIPHYS SEPARATION","25606","CPT","20000306","CDM","450","RC","","Facility","Inpatient","","","1894","1515.20","1268.98","67","","","Percent of Total Billed Charges","neg_dollar:$1268.98","1894.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1268.98","67","","","Percent of Total Billed Charges","neg_dollar:$1268.98","1894.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1894.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1894.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1628.84","86","","","Percent of Total Billed Charges","neg_dollar:$1628.84","1325.80","70","","","Percent of Total Billed Charges","neg_dollar:$1325.80","1894.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1894.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1420.50","75","","","Percent of Total Billed Charges","neg_dollar:$1420.50","1628.84","86","","","Percent of Total Billed Charges","neg_dollar:$1628.84","1325.80","70","","","Percent of Total Billed Charges","neg_dollar:$1325.80","1894.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1894.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1515.20","80","","","Percent of Total Billed Charges","neg_dollar:$1515.20;Percent of Total Billed Charges","1742.48","92","","","Percent of Total Billed Charges","neg_dollar:$1742.48","1894.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1894.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1268.00","1894.00",""
"TENDON SHEATH INCISION","26055","CPT","20000381","CDM","360","RC","","Facility","Inpatient","","","1759","1407.20","1178.53","67","","","Percent of Total Billed Charges","neg_dollar:$1178.53","1759.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1178.53","67","","","Percent of Total Billed Charges","neg_dollar:$1178.53","1759.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1759.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1759.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1512.74","86","","","Percent of Total Billed Charges","neg_dollar:$1512.74","1231.30","70","","","Percent of Total Billed Charges","neg_dollar:$1231.30","1759.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1759.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1319.25","75","","","Percent of Total Billed Charges","neg_dollar:$1319.25","1512.74","86","","","Percent of Total Billed Charges","neg_dollar:$1512.74","1231.30","70","","","Percent of Total Billed Charges","neg_dollar:$1231.30","1759.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1759.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1407.20","80","","","Percent of Total Billed Charges","neg_dollar:$1407.20;Percent of Total Billed Charges","1618.28","92","","","Percent of Total Billed Charges","neg_dollar:$1618.28","1759.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1759.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1178.00","1759.00",""
"PALM W SGL DIGIT RELEASE","26123","CPT","20000490","CDM","360","RC","","Facility","Inpatient","","","2428","1942.40","1626.76","67","","","Percent of Total Billed Charges","neg_dollar:$1626.76","2428.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1626.76","67","","","Percent of Total Billed Charges","neg_dollar:$1626.76","2428.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2428.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2428.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2088.08","86","","","Percent of Total Billed Charges","neg_dollar:$2088.08","1699.60","70","","","Percent of Total Billed Charges","neg_dollar:$1699.60","2428.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2428.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1821.00","75","","","Percent of Total Billed Charges","neg_dollar:$1821","2088.08","86","","","Percent of Total Billed Charges","neg_dollar:$2088.08","1699.60","70","","","Percent of Total Billed Charges","neg_dollar:$1699.60","2428.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2428.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1942.40","80","","","Percent of Total Billed Charges","neg_dollar:$1942.40;Percent of Total Billed Charges","2233.76","92","","","Percent of Total Billed Charges","neg_dollar:$2233.76","2428.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2428.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1626.00","2428.00",""
"EXTENSOR TENDON REPAIR FINGER EACH","26418","CPT","20000042","CDM","360","RC","","Facility","Inpatient","","","2578","2062.40","1727.26","67","","","Percent of Total Billed Charges","neg_dollar:$1727.26","2578.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1727.26","67","","","Percent of Total Billed Charges","neg_dollar:$1727.26","2578.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2578.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2578.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2217.08","86","","","Percent of Total Billed Charges","neg_dollar:$2217.08","1804.60","70","","","Percent of Total Billed Charges","neg_dollar:$1804.60","2578.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2578.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1933.50","75","","","Percent of Total Billed Charges","neg_dollar:$1933.50","2217.08","86","","","Percent of Total Billed Charges","neg_dollar:$2217.08","1804.60","70","","","Percent of Total Billed Charges","neg_dollar:$1804.60","2578.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2578.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","2062.40","80","","","Percent of Total Billed Charges","neg_dollar:$2062.40;Percent of Total Billed Charges","2371.76","92","","","Percent of Total Billed Charges","neg_dollar:$2371.76","2578.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2578.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1727.00","2578.00",""
"CL TX MC FX SGL W MANIP","26605","CPT","20000044","CDM","450","RC","","Facility","Inpatient","","","1006","804.80","674.02","67","","","Percent of Total Billed Charges","neg_dollar:$674.02","1006.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","674.02","67","","","Percent of Total Billed Charges","neg_dollar:$674.02","1006.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1006.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1006.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","865.16","86","","","Percent of Total Billed Charges","neg_dollar:$865.16","704.19","70","","","Percent of Total Billed Charges","neg_dollar:$704.19","1006.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1006.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","754.50","75","","","Percent of Total Billed Charges","neg_dollar:$754.50","865.16","86","","","Percent of Total Billed Charges","neg_dollar:$865.16","704.19","70","","","Percent of Total Billed Charges","neg_dollar:$704.19","1006.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1006.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","804.80","80","","","Percent of Total Billed Charges","neg_dollar:$804.80;Percent of Total Billed Charges","925.52","92","","","Percent of Total Billed Charges","neg_dollar:$925.52","1006.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1006.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","674.00","1006.00",""
"CL TX PHALANG SHFT FX W MANIP","26725","CPT","20000049","CDM","450","RC","","Facility","Inpatient","","","744","595.20","498.48","67","","","Percent of Total Billed Charges","neg_dollar:$498.48","744.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","498.48","67","","","Percent of Total Billed Charges","neg_dollar:$498.48","744.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","744.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","744.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","639.84","86","","","Percent of Total Billed Charges","neg_dollar:$639.84","520.80","70","","","Percent of Total Billed Charges","neg_dollar:$520.80","744.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","744.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","558.00","75","","","Percent of Total Billed Charges","neg_dollar:$558","639.84","86","","","Percent of Total Billed Charges","neg_dollar:$639.84","520.80","70","","","Percent of Total Billed Charges","neg_dollar:$520.80","744.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","744.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","595.20","80","","","Percent of Total Billed Charges","neg_dollar:$595.20;Percent of Total Billed Charges","684.48","92","","","Percent of Total Billed Charges","neg_dollar:$684.48","744.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","744.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","498.00","744.00",""
"CL TX ART FX MCP/IP JNT W MANIP","26742","CPT","20000050","CDM","450","RC","","Facility","Inpatient","","","860","688.00","576.20","67","","","Percent of Total Billed Charges","neg_dollar:$576.20","860.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","576.20","67","","","Percent of Total Billed Charges","neg_dollar:$576.20","860.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","860.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","860.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","860.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","860.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","645.00","75","","","Percent of Total Billed Charges","neg_dollar:$645","739.60","86","","","Percent of Total Billed Charges","neg_dollar:$739.60","602.00","70","","","Percent of Total Billed Charges","neg_dollar:$602","860.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","860.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","688.00","80","","","Percent of Total Billed Charges","neg_dollar:$688;Percent of Total Billed Charges","791.20","92","","","Percent of Total Billed Charges","neg_dollar:$791.20","860.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","860.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","576.00","860.00",""
"CL TX D PHAL FX FGR/THMB W MANIP","26755","CPT","20000052","CDM","450","RC","","Facility","Inpatient","","","424","339.20","284.08","67","","","Percent of Total Billed Charges","neg_dollar:$284.08","424.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","284.08","67","","","Percent of Total Billed Charges","neg_dollar:$284.08","424.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","424.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","424.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","424.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","424.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","318.00","75","","","Percent of Total Billed Charges","neg_dollar:$318","364.64","86","","","Percent of Total Billed Charges","neg_dollar:$364.64","296.79","70","","","Percent of Total Billed Charges","neg_dollar:$296.79","424.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","424.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","339.20","80","","","Percent of Total Billed Charges","neg_dollar:$339.20;Percent of Total Billed Charges","390.08","92","","","Percent of Total Billed Charges","neg_dollar:$390.08","424.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","424.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","284.00","424.00",""
"OPEN TX D PHAL FX FGR/THMB EACH","26765","CPT","20000149","CDM","450","RC","","Facility","Inpatient","","","7214","5771.20","4833.38","67","","","Percent of Total Billed Charges","neg_dollar:$4833.38","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","4833.38","67","","","Percent of Total Billed Charges","neg_dollar:$4833.38","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","6204.04","86","","","Percent of Total Billed Charges","neg_dollar:$6204.04","5049.79","70","","","Percent of Total Billed Charges","neg_dollar:$5049.79","4432.05","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","7214.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","5410.50","75","","","Percent of Total Billed Charges","neg_dollar:$5410.50","6204.04","86","","","Percent of Total Billed Charges","neg_dollar:$6204.04","5049.79","70","","","Percent of Total Billed Charges","neg_dollar:$5049.79","7214.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","7214.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","5771.20","80","","","Percent of Total Billed Charges","neg_dollar:$5771.20;Percent of Total Billed Charges","6636.88","92","","","Percent of Total Billed Charges","neg_dollar:$6636.88","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","7214.00",""
"CL TX IP JNT D W MANIP WO ANESTH","26770","CPT","20000053","CDM","450","RC","","Facility","Inpatient","","","656","524.80","439.52","67","","","Percent of Total Billed Charges","neg_dollar:$439.52","656.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","439.52","67","","","Percent of Total Billed Charges","neg_dollar:$439.52","656.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","656.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","656.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","564.16","86","","","Percent of Total Billed Charges","neg_dollar:$564.16","459.20","70","","","Percent of Total Billed Charges","neg_dollar:$459.20","656.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","656.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","492.00","75","","","Percent of Total Billed Charges","neg_dollar:$492","564.16","86","","","Percent of Total Billed Charges","neg_dollar:$564.16","459.20","70","","","Percent of Total Billed Charges","neg_dollar:$459.20","656.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","656.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","524.80","80","","","Percent of Total Billed Charges","neg_dollar:$524.80;Percent of Total Billed Charges","603.52","92","","","Percent of Total Billed Charges","neg_dollar:$603.52","656.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","656.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","439.00","656.00",""
"INJ ARTHROGRAM HIP W/O ANESTH","27093","CPT","20000192","CDM","360","RC","","Facility","Inpatient","","","463","370.40","310.21","67","","","Percent of Total Billed Charges","neg_dollar:$310.21","463.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","310.21","67","","","Percent of Total Billed Charges","neg_dollar:$310.21","463.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","463.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","463.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","398.18","86","","","Percent of Total Billed Charges","neg_dollar:$398.18","324.09","70","","","Percent of Total Billed Charges","neg_dollar:$324.09","463.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","463.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","347.25","75","","","Percent of Total Billed Charges","neg_dollar:$347.25","398.18","86","","","Percent of Total Billed Charges","neg_dollar:$398.18","324.09","70","","","Percent of Total Billed Charges","neg_dollar:$324.09","463.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","463.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","370.40","80","","","Percent of Total Billed Charges","neg_dollar:$370.40;Percent of Total Billed Charges","425.96","92","","","Percent of Total Billed Charges","neg_dollar:$425.96","463.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","463.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","310.00","463.00",""
"SIJ ANESTH/STERIOD INJ PAIN","27096","CPT","20000119","CDM","761","RC","","Facility","Inpatient","","","2115","1692.00","1417.05","67","","","Percent of Total Billed Charges","neg_dollar:$1417.05","2115.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1417.05","67","","","Percent of Total Billed Charges","neg_dollar:$1417.05","2115.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2115.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2115.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1818.89","86","","","Percent of Total Billed Charges","neg_dollar:$1818.89","1480.50","70","","","Percent of Total Billed Charges","neg_dollar:$1480.50","2115.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2115.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1586.25","75","","","Percent of Total Billed Charges","neg_dollar:$1586.25","1818.89","86","","","Percent of Total Billed Charges","neg_dollar:$1818.89","1480.50","70","","","Percent of Total Billed Charges","neg_dollar:$1480.50","2115.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2115.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1692.00","80","","","Percent of Total Billed Charges","neg_dollar:$1692;Percent of Total Billed Charges","1945.80","92","","","Percent of Total Billed Charges","neg_dollar:$1945.80","2115.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2115.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1417.00","2115.00",""
"SIJ ANESTH/STERIOD INJ PAIN BILAT","27096","CPT","20000120","CDM","761","RC","50","Facility","Inpatient","","","3170","2536.00","2123.90","67","","","Percent of Total Billed Charges","neg_dollar:$2123.90","3170.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2123.90","67","","","Percent of Total Billed Charges","neg_dollar:$2123.90","3170.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3170.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3170.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2726.20","86","","","Percent of Total Billed Charges","neg_dollar:$2726.20","2219.00","70","","","Percent of Total Billed Charges","neg_dollar:$2219","3170.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","3170.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","2377.50","75","","","Percent of Total Billed Charges","neg_dollar:$2377.50","2726.20","86","","","Percent of Total Billed Charges","neg_dollar:$2726.20","2219.00","70","","","Percent of Total Billed Charges","neg_dollar:$2219","3170.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","3170.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","2536.00","80","","","Percent of Total Billed Charges","neg_dollar:$2536;Percent of Total Billed Charges","2916.40","92","","","Percent of Total Billed Charges","neg_dollar:$2916.40","3170.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3170.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2123.00","3170.00",""
"DX INJ SI JOINT ARTHROGRAPHY","27096","CPT","20000337","CDM","761","RC","","Facility","Inpatient","","","1318","1054.40","883.06","67","","","Percent of Total Billed Charges","neg_dollar:$883.06","1318.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","883.06","67","","","Percent of Total Billed Charges","neg_dollar:$883.06","1318.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1318.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1318.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","1318.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1318.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","988.50","75","","","Percent of Total Billed Charges","neg_dollar:$988.50","1133.48","86","","","Percent of Total Billed Charges","neg_dollar:$1133.48","922.59","70","","","Percent of Total Billed Charges","neg_dollar:$922.59","1318.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1318.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1054.40","80","","","Percent of Total Billed Charges","neg_dollar:$1054.40;Percent of Total Billed Charges","1212.56","92","","","Percent of Total Billed Charges","neg_dollar:$1212.56","1318.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1318.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","883.00","1318.00",""
"CL TX POST HIP DISLOC WO ANESTH","27265","CPT","20000058","CDM","450","RC","","Facility","Inpatient","","","1308","1046.40","876.36","67","","","Percent of Total Billed Charges","neg_dollar:$876.36","1308.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","876.36","67","","","Percent of Total Billed Charges","neg_dollar:$876.36","1308.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1308.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1308.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1124.87","86","","","Percent of Total Billed Charges","neg_dollar:$1124.87","915.59","70","","","Percent of Total Billed Charges","neg_dollar:$915.59","1308.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1308.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","981.00","75","","","Percent of Total Billed Charges","neg_dollar:$981","1124.87","86","","","Percent of Total Billed Charges","neg_dollar:$1124.87","915.59","70","","","Percent of Total Billed Charges","neg_dollar:$915.59","1308.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1308.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1046.40","80","","","Percent of Total Billed Charges","neg_dollar:$1046.40;Percent of Total Billed Charges","1203.36","92","","","Percent of Total Billed Charges","neg_dollar:$1203.36","1308.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1308.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","876.00","1308.00",""
"CL TX FEMORAL SHAFT FX W MANIP","27502","CPT","20000259","CDM","450","RC","","Facility","Inpatient","","","2922","2337.60","1957.74","67","","","Percent of Total Billed Charges","neg_dollar:$1957.74","2922.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1957.74","67","","","Percent of Total Billed Charges","neg_dollar:$1957.74","2922.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2922.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2922.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2512.92","86","","","Percent of Total Billed Charges","neg_dollar:$2512.92","2045.39","70","","","Percent of Total Billed Charges","neg_dollar:$2045.39","2922.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2922.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","2191.50","75","","","Percent of Total Billed Charges","neg_dollar:$2191.50","2512.92","86","","","Percent of Total Billed Charges","neg_dollar:$2512.92","2045.39","70","","","Percent of Total Billed Charges","neg_dollar:$2045.39","2922.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2922.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","2337.60","80","","","Percent of Total Billed Charges","neg_dollar:$2337.60;Percent of Total Billed Charges","2688.24","92","","","Percent of Total Billed Charges","neg_dollar:$2688.24","2922.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2922.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1957.00","2922.00",""
"CL TX PATELLAR DISLOCATION WO ANESTH","27560","CPT","20000063","CDM","450","RC","","Facility","Inpatient","","","284","227.20","190.28","67","","","Percent of Total Billed Charges","neg_dollar:$190.28","284.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","190.28","67","","","Percent of Total Billed Charges","neg_dollar:$190.28","284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","284.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","284.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","284.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","213.00","75","","","Percent of Total Billed Charges","neg_dollar:$213","244.24","86","","","Percent of Total Billed Charges","neg_dollar:$244.24","198.79","70","","","Percent of Total Billed Charges","neg_dollar:$198.79","284.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","284.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","227.20","80","","","Percent of Total Billed Charges","neg_dollar:$227.20;Percent of Total Billed Charges","261.28","92","","","Percent of Total Billed Charges","neg_dollar:$261.28","284.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","284.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","190.00","284.00",""
"CL TX BIMALLEOLAR ANKLE FX W MANIP","27810","CPT","20000073","CDM","450","RC","","Facility","Inpatient","","","404","323.20","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","270.68","67","","","Percent of Total Billed Charges","neg_dollar:$270.68","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","404.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","303.00","75","","","Percent of Total Billed Charges","neg_dollar:$303","347.44","86","","","Percent of Total Billed Charges","neg_dollar:$347.44","282.79","70","","","Percent of Total Billed Charges","neg_dollar:$282.79","404.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","404.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","323.20","80","","","Percent of Total Billed Charges","neg_dollar:$323.20;Percent of Total Billed Charges","371.68","92","","","Percent of Total Billed Charges","neg_dollar:$371.68","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","404.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","270.00","404.00",""
"CL TX TRIMALL ANKLE FX W MANIP","27818","CPT","20000075","CDM","450","RC","","Facility","Inpatient","","","1594","1275.20","1067.98","67","","","Percent of Total Billed Charges","neg_dollar:$1067.98","1594.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1067.98","67","","","Percent of Total Billed Charges","neg_dollar:$1067.98","1594.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1594.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1594.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1370.84","86","","","Percent of Total Billed Charges","neg_dollar:$1370.84","1115.80","70","","","Percent of Total Billed Charges","neg_dollar:$1115.80","1594.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1594.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1195.50","75","","","Percent of Total Billed Charges","neg_dollar:$1195.50","1370.84","86","","","Percent of Total Billed Charges","neg_dollar:$1370.84","1115.80","70","","","Percent of Total Billed Charges","neg_dollar:$1115.80","1594.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1594.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1275.20","80","","","Percent of Total Billed Charges","neg_dollar:$1275.20;Percent of Total Billed Charges","1466.48","92","","","Percent of Total Billed Charges","neg_dollar:$1466.48","1594.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1594.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1067.00","1594.00",""
"REM FB FOOT SQ","28190","CPT","20000117","CDM","360","RC","","Facility","Inpatient","","","2101","1680.80","1407.67","67","","","Percent of Total Billed Charges","neg_dollar:$1407.67","2101.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1407.67","67","","","Percent of Total Billed Charges","neg_dollar:$1407.67","2101.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2101.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2101.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1806.86","86","","","Percent of Total Billed Charges","neg_dollar:$1806.86","1470.69","70","","","Percent of Total Billed Charges","neg_dollar:$1470.69","2101.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2101.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1575.75","75","","","Percent of Total Billed Charges","neg_dollar:$1575.75","1806.86","86","","","Percent of Total Billed Charges","neg_dollar:$1806.86","1470.69","70","","","Percent of Total Billed Charges","neg_dollar:$1470.69","2101.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2101.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1680.80","80","","","Percent of Total Billed Charges","neg_dollar:$1680.80;Percent of Total Billed Charges","1932.92","92","","","Percent of Total Billed Charges","neg_dollar:$1932.92","2101.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2101.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1407.00","2101.00",""
"CL TX TALUS FX W MANIP","28435","CPT","20000210","CDM","450","RC","","Facility","Inpatient","","","355","284.00","237.85","67","","","Percent of Total Billed Charges","neg_dollar:$237.85","355.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","237.85","67","","","Percent of Total Billed Charges","neg_dollar:$237.85","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","355.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","355.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","266.25","75","","","Percent of Total Billed Charges","neg_dollar:$266.25","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","355.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","355.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","284.00","80","","","Percent of Total Billed Charges","neg_dollar:$284;Percent of Total Billed Charges","326.60","92","","","Percent of Total Billed Charges","neg_dollar:$326.60","355.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","237.00","355.00",""
"CL TX FX GT PHALANX W MANIP","28495","CPT","20000085","CDM","450","RC","","Facility","Inpatient","","","355","284.00","237.85","67","","","Percent of Total Billed Charges","neg_dollar:$237.85","355.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","237.85","67","","","Percent of Total Billed Charges","neg_dollar:$237.85","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","355.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","355.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","266.25","75","","","Percent of Total Billed Charges","neg_dollar:$266.25","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","355.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","355.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","284.00","80","","","Percent of Total Billed Charges","neg_dollar:$284;Percent of Total Billed Charges","326.60","92","","","Percent of Total Billed Charges","neg_dollar:$326.60","355.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","237.00","355.00",""
"CL TX FX PHALANX/PHALANG W MANIP","28515","CPT","20000087","CDM","450","RC","","Facility","Inpatient","","","659","527.20","441.53","67","","","Percent of Total Billed Charges","neg_dollar:$441.53","659.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","441.53","67","","","Percent of Total Billed Charges","neg_dollar:$441.53","659.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","659.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","659.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","566.74","86","","","Percent of Total Billed Charges","neg_dollar:$566.74","461.29","70","","","Percent of Total Billed Charges","neg_dollar:$461.29","659.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","659.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","494.25","75","","","Percent of Total Billed Charges","neg_dollar:$494.25","566.74","86","","","Percent of Total Billed Charges","neg_dollar:$566.74","461.29","70","","","Percent of Total Billed Charges","neg_dollar:$461.29","659.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","659.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","527.20","80","","","Percent of Total Billed Charges","neg_dollar:$527.20;Percent of Total Billed Charges","606.28","92","","","Percent of Total Billed Charges","neg_dollar:$606.28","659.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","659.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","441.00","659.00",""
"AMPUTATE TOE; MTP JOINT","28820","CPT","20000267","CDM","761","RC","","Facility","Inpatient","","","1863","1490.40","1248.21","67","","","Percent of Total Billed Charges","neg_dollar:$1248.21","1863.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1248.21","67","","","Percent of Total Billed Charges","neg_dollar:$1248.21","1863.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1863.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1863.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1602.18","86","","","Percent of Total Billed Charges","neg_dollar:$1602.18","1304.10","70","","","Percent of Total Billed Charges","neg_dollar:$1304.10","1863.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1863.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1397.25","75","","","Percent of Total Billed Charges","neg_dollar:$1397.25","1602.18","86","","","Percent of Total Billed Charges","neg_dollar:$1602.18","1304.10","70","","","Percent of Total Billed Charges","neg_dollar:$1304.10","1863.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1863.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1490.40","80","","","Percent of Total Billed Charges","neg_dollar:$1490.40;Percent of Total Billed Charges","1713.96","92","","","Percent of Total Billed Charges","neg_dollar:$1713.96","1863.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1863.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1248.00","1863.00",""
"APPLY SHORT ARM CAST","29075","CPT","20000092","CDM","360","RC","","Facility","Inpatient","","","297","237.60","198.99","67","","","Percent of Total Billed Charges","neg_dollar:$198.99","297.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","198.99","67","","","Percent of Total Billed Charges","neg_dollar:$198.99","297.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","297.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","297.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","297.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","297.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","222.75","75","","","Percent of Total Billed Charges","neg_dollar:$222.75","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","297.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","297.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","237.60","80","","","Percent of Total Billed Charges","neg_dollar:$237.60;Percent of Total Billed Charges","273.24","92","","","Percent of Total Billed Charges","neg_dollar:$273.24","297.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","297.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","198.00","297.00",""
"APPLY LONG ARM SPLINT","29105","CPT","20000094","CDM","360","RC","","Facility","Inpatient","","","292","233.60","195.64","67","","","Percent of Total Billed Charges","neg_dollar:$195.64","292.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","195.64","67","","","Percent of Total Billed Charges","neg_dollar:$195.64","292.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","292.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","292.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","251.12","86","","","Percent of Total Billed Charges","neg_dollar:$251.12","204.39","70","","","Percent of Total Billed Charges","neg_dollar:$204.39","292.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","292.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","219.00","75","","","Percent of Total Billed Charges","neg_dollar:$219","251.12","86","","","Percent of Total Billed Charges","neg_dollar:$251.12","204.39","70","","","Percent of Total Billed Charges","neg_dollar:$204.39","292.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","292.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","233.60","80","","","Percent of Total Billed Charges","neg_dollar:$233.60;Percent of Total Billed Charges","268.64","92","","","Percent of Total Billed Charges","neg_dollar:$268.64","292.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","292.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","195.00","292.00",""
"APPLY SHORT ARM SPLINT STATIC","29125","CPT","20000095","CDM","360","RC","","Facility","Inpatient","","","297","237.60","198.99","67","","","Percent of Total Billed Charges","neg_dollar:$198.99","297.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","198.99","67","","","Percent of Total Billed Charges","neg_dollar:$198.99","297.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","297.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","297.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","297.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","297.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","222.75","75","","","Percent of Total Billed Charges","neg_dollar:$222.75","255.42","86","","","Percent of Total Billed Charges","neg_dollar:$255.42","207.89","70","","","Percent of Total Billed Charges","neg_dollar:$207.89","297.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","297.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","237.60","80","","","Percent of Total Billed Charges","neg_dollar:$237.60;Percent of Total Billed Charges","273.24","92","","","Percent of Total Billed Charges","neg_dollar:$273.24","297.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","297.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","198.00","297.00",""
"APPLY SHORT ARM SPLINT DYNAMIC","29126","CPT","20000299","CDM","761","RC","","Facility","Inpatient","","","171","136.80","114.57","67","","","Percent of Total Billed Charges","neg_dollar:$114.57","171.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","114.57","67","","","Percent of Total Billed Charges","neg_dollar:$114.57","171.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","171.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","171.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","147.06","86","","","Percent of Total Billed Charges","neg_dollar:$147.06","119.69","70","","","Percent of Total Billed Charges","neg_dollar:$119.69","171.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","171.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","128.25","75","","","Percent of Total Billed Charges","neg_dollar:$128.25","147.06","86","","","Percent of Total Billed Charges","neg_dollar:$147.06","119.69","70","","","Percent of Total Billed Charges","neg_dollar:$119.69","171.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","171.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","136.80","80","","","Percent of Total Billed Charges","neg_dollar:$136.80;Percent of Total Billed Charges","157.32","92","","","Percent of Total Billed Charges","neg_dollar:$157.32","171.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","171.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","114.00","171.00",""
"APPLY FINGER SPLINT STATIC","29130","CPT","20000096","CDM","360","RC","","Facility","Inpatient","","","170","136.00","113.90","67","","","Percent of Total Billed Charges","neg_dollar:$113.90","170.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","113.90","67","","","Percent of Total Billed Charges","neg_dollar:$113.90","170.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","170.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","170.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","146.20","86","","","Percent of Total Billed Charges","neg_dollar:$146.20","118.99","70","","","Percent of Total Billed Charges","neg_dollar:$118.99","170.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","170.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","127.50","75","","","Percent of Total Billed Charges","neg_dollar:$127.50","146.20","86","","","Percent of Total Billed Charges","neg_dollar:$146.20","118.99","70","","","Percent of Total Billed Charges","neg_dollar:$118.99","170.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","170.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","136.00","80","","","Percent of Total Billed Charges","neg_dollar:$136;Percent of Total Billed Charges","156.40","92","","","Percent of Total Billed Charges","neg_dollar:$156.40","170.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","170.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","113.00","170.00",""
"APPLY FINGER SPLINT DYNAMIC","29131","CPT","20000300","CDM","761","RC","","Facility","Inpatient","","","113","90.40","75.71","67","","","Percent of Total Billed Charges","neg_dollar:$75.71","113.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","75.71","67","","","Percent of Total Billed Charges","neg_dollar:$75.71","113.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","113.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","113.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","97.17","86","","","Percent of Total Billed Charges","neg_dollar:$97.17","79.10","70","","","Percent of Total Billed Charges","neg_dollar:$79.10","113.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","113.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","84.75","75","","","Percent of Total Billed Charges","neg_dollar:$84.75","97.17","86","","","Percent of Total Billed Charges","neg_dollar:$97.17","79.10","70","","","Percent of Total Billed Charges","neg_dollar:$79.10","113.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","113.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","90.40","80","","","Percent of Total Billed Charges","neg_dollar:$90.40;Percent of Total Billed Charges","103.96","92","","","Percent of Total Billed Charges","neg_dollar:$103.96","113.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","113.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","75.00","113.00",""
"APPLY RIGID TOTAL CONTACT LEG CAST","29445","CPT","20000102","CDM","761","RC","","Facility","Inpatient","","","524","419.20","351.08","67","","","Percent of Total Billed Charges","neg_dollar:$351.08","524.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","351.08","67","","","Percent of Total Billed Charges","neg_dollar:$351.08","524.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","524.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","524.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","450.64","86","","","Percent of Total Billed Charges","neg_dollar:$450.64","366.79","70","","","Percent of Total Billed Charges","neg_dollar:$366.79","524.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","524.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","393.00","75","","","Percent of Total Billed Charges","neg_dollar:$393","450.64","86","","","Percent of Total Billed Charges","neg_dollar:$450.64","366.79","70","","","Percent of Total Billed Charges","neg_dollar:$366.79","524.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","524.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","419.20","80","","","Percent of Total Billed Charges","neg_dollar:$419.20;Percent of Total Billed Charges","482.08","92","","","Percent of Total Billed Charges","neg_dollar:$482.08","524.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","524.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","351.00","524.00",""
"APPLY LONG LEG SPLINT","29505","CPT","20000103","CDM","360","RC","","Facility","Inpatient","","","222","177.60","148.74","67","","","Percent of Total Billed Charges","neg_dollar:$148.74","222.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","148.74","67","","","Percent of Total Billed Charges","neg_dollar:$148.74","222.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","222.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","222.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","190.92","86","","","Percent of Total Billed Charges","neg_dollar:$190.92","155.39","70","","","Percent of Total Billed Charges","neg_dollar:$155.39","222.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","222.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","166.50","75","","","Percent of Total Billed Charges","neg_dollar:$166.50","190.92","86","","","Percent of Total Billed Charges","neg_dollar:$190.92","155.39","70","","","Percent of Total Billed Charges","neg_dollar:$155.39","222.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","222.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","177.60","80","","","Percent of Total Billed Charges","neg_dollar:$177.60;Percent of Total Billed Charges","204.24","92","","","Percent of Total Billed Charges","neg_dollar:$204.24","222.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","222.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","148.00","222.00",""
"APPLY SHORT LEG SPLINT","29515","CPT","20000104","CDM","360","RC","","Facility","Inpatient","","","198","158.40","132.66","67","","","Percent of Total Billed Charges","neg_dollar:$132.66","198.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","132.66","67","","","Percent of Total Billed Charges","neg_dollar:$132.66","198.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","198.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","198.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","170.28","86","","","Percent of Total Billed Charges","neg_dollar:$170.28","138.60","70","","","Percent of Total Billed Charges","neg_dollar:$138.60","198.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","198.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","148.50","75","","","Percent of Total Billed Charges","neg_dollar:$148.50","170.28","86","","","Percent of Total Billed Charges","neg_dollar:$170.28","138.60","70","","","Percent of Total Billed Charges","neg_dollar:$138.60","198.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","198.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","158.40","80","","","Percent of Total Billed Charges","neg_dollar:$158.40;Percent of Total Billed Charges","182.16","92","","","Percent of Total Billed Charges","neg_dollar:$182.16","198.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","198.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","132.00","198.00",""
"UNNA BOOT STRAPPING","29580","CPT","20000106","CDM","761","RC","","Facility","Inpatient","","","482","385.60","322.94","67","","","Percent of Total Billed Charges","neg_dollar:$322.94","482.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","322.94","67","","","Percent of Total Billed Charges","neg_dollar:$322.94","482.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","482.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","482.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","414.52","86","","","Percent of Total Billed Charges","neg_dollar:$414.52","337.40","70","","","Percent of Total Billed Charges","neg_dollar:$337.40","482.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","482.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","361.50","75","","","Percent of Total Billed Charges","neg_dollar:$361.50","414.52","86","","","Percent of Total Billed Charges","neg_dollar:$414.52","337.40","70","","","Percent of Total Billed Charges","neg_dollar:$337.40","482.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","482.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","385.60","80","","","Percent of Total Billed Charges","neg_dollar:$385.60;Percent of Total Billed Charges","443.44","92","","","Percent of Total Billed Charges","neg_dollar:$443.44","482.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","482.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","322.00","482.00",""
"APPLY MULTLAY COMPRS LWR LEG","29581","CPT","20000107","CDM","761","RC","","Facility","Inpatient","","","363","290.40","243.21","67","","","Percent of Total Billed Charges","neg_dollar:$243.21","363.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","243.21","67","","","Percent of Total Billed Charges","neg_dollar:$243.21","363.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","363.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","363.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","312.18","86","","","Percent of Total Billed Charges","neg_dollar:$312.18","254.10","70","","","Percent of Total Billed Charges","neg_dollar:$254.10","363.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","363.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","272.25","75","","","Percent of Total Billed Charges","neg_dollar:$272.25","312.18","86","","","Percent of Total Billed Charges","neg_dollar:$312.18","254.10","70","","","Percent of Total Billed Charges","neg_dollar:$254.10","363.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","363.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","290.40","80","","","Percent of Total Billed Charges","neg_dollar:$290.40;Percent of Total Billed Charges","333.96","92","","","Percent of Total Billed Charges","neg_dollar:$333.96","363.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","363.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","243.00","363.00",""
"APPLY MULTLAY COMPRS LWR LEG BILAT","29581","CPT","20000169","CDM","761","RC","50","Facility","Inpatient","","","497","397.60","332.99","67","","","Percent of Total Billed Charges","neg_dollar:$332.99","497.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","332.99","67","","","Percent of Total Billed Charges","neg_dollar:$332.99","497.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","497.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","497.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","427.42","86","","","Percent of Total Billed Charges","neg_dollar:$427.42","347.90","70","","","Percent of Total Billed Charges","neg_dollar:$347.90","497.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","497.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","372.75","75","","","Percent of Total Billed Charges","neg_dollar:$372.75","427.42","86","","","Percent of Total Billed Charges","neg_dollar:$427.42","347.90","70","","","Percent of Total Billed Charges","neg_dollar:$347.90","497.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","497.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","397.60","80","","","Percent of Total Billed Charges","neg_dollar:$397.60;Percent of Total Billed Charges","457.24","92","","","Percent of Total Billed Charges","neg_dollar:$457.24","497.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","497.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","332.00","497.00",""
"APPLY MULTLAY COMPRS ARM/HAND","29584","CPT","20000340","CDM","761","RC","","Facility","Inpatient","","","335","268.00","224.45","67","","","Percent of Total Billed Charges","neg_dollar:$224.45","335.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","224.45","67","","","Percent of Total Billed Charges","neg_dollar:$224.45","335.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","335.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","335.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","288.10","86","","","Percent of Total Billed Charges","neg_dollar:$288.10","234.49","70","","","Percent of Total Billed Charges","neg_dollar:$234.49","335.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","335.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","251.25","75","","","Percent of Total Billed Charges","neg_dollar:$251.25","288.10","86","","","Percent of Total Billed Charges","neg_dollar:$288.10","234.49","70","","","Percent of Total Billed Charges","neg_dollar:$234.49","335.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","335.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","268.00","80","","","Percent of Total Billed Charges","neg_dollar:$268;Percent of Total Billed Charges","308.20","92","","","Percent of Total Billed Charges","neg_dollar:$308.20","335.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","335.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","224.00","335.00",""
"ARTHROSCOPY BICEPS TENODESIS","29828","CPT","20000524","CDM","360","RC","","Facility","Inpatient","","","4158","3326.40","2785.86","67","","","Percent of Total Billed Charges","neg_dollar:$2785.86","4158.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2785.86","67","","","Percent of Total Billed Charges","neg_dollar:$2785.86","4158.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4158.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4158.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3575.88","86","","","Percent of Total Billed Charges","neg_dollar:$3575.88","2910.60","70","","","Percent of Total Billed Charges","neg_dollar:$2910.60","4158.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4158.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3118.50","75","","","Percent of Total Billed Charges","neg_dollar:$3118.50","3575.88","86","","","Percent of Total Billed Charges","neg_dollar:$3575.88","2910.60","70","","","Percent of Total Billed Charges","neg_dollar:$2910.60","4158.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4158.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3326.40","80","","","Percent of Total Billed Charges","neg_dollar:$3326.40;Percent of Total Billed Charges","3825.36","92","","","Percent of Total Billed Charges","neg_dollar:$3825.36","4158.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4158.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2785.00","4158.00",""
"ARTHROSCOPY WRIST; W RLS TRNSV CARP LIG","29848","CPT","20000525","CDM","360","RC","","Facility","Inpatient","","","1477","1181.60","989.59","67","","","Percent of Total Billed Charges","neg_dollar:$989.59","1477.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","989.59","67","","","Percent of Total Billed Charges","neg_dollar:$989.59","1477.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1477.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1477.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1270.22","86","","","Percent of Total Billed Charges","neg_dollar:$1270.22","1033.89","70","","","Percent of Total Billed Charges","neg_dollar:$1033.89","1477.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1477.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1107.75","75","","","Percent of Total Billed Charges","neg_dollar:$1107.75","1270.22","86","","","Percent of Total Billed Charges","neg_dollar:$1270.22","1033.89","70","","","Percent of Total Billed Charges","neg_dollar:$1033.89","1477.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1477.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1181.60","80","","","Percent of Total Billed Charges","neg_dollar:$1181.60;Percent of Total Billed Charges","1358.84","92","","","Percent of Total Billed Charges","neg_dollar:$1358.84","1477.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1477.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","989.00","1477.00",""
"KNEE ARTHROSCOPY/SURGERY","29880","CPT","20000529","CDM","360","RC","","Facility","Inpatient","","","4322","3457.60","2895.74","67","","","Percent of Total Billed Charges","neg_dollar:$2895.74","4263.21","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2895.74","67","","","Percent of Total Billed Charges","neg_dollar:$2895.74","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","4305.42","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3716.92","86","","","Percent of Total Billed Charges","neg_dollar:$3716.92","3025.39","70","","","Percent of Total Billed Charges","neg_dollar:$3025.39","4322.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","4322.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","3241.50","75","","","Percent of Total Billed Charges","neg_dollar:$3241.50","3716.92","86","","","Percent of Total Billed Charges","neg_dollar:$3716.92","3025.39","70","","","Percent of Total Billed Charges","neg_dollar:$3025.39","4322.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","4322.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","3457.60","80","","","Percent of Total Billed Charges","neg_dollar:$3457.60;Percent of Total Billed Charges","3976.24","92","","","Percent of Total Billed Charges","neg_dollar:$3976.24","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","4221.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2895.00","4322.00",""
"KNEE ARTHROSCOPY/SURGERY","29881","CPT","20000391","CDM","360","RC","","Facility","Inpatient","","","3615","2892.00","2422.05","67","","","Percent of Total Billed Charges","neg_dollar:$2422.05","3615.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2422.05","67","","","Percent of Total Billed Charges","neg_dollar:$2422.05","3615.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3615.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3615.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3108.90","86","","","Percent of Total Billed Charges","neg_dollar:$3108.90","2530.50","70","","","Percent of Total Billed Charges","neg_dollar:$2530.50","3615.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","3615.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","2711.25","75","","","Percent of Total Billed Charges","neg_dollar:$2711.25","3108.90","86","","","Percent of Total Billed Charges","neg_dollar:$3108.90","2530.50","70","","","Percent of Total Billed Charges","neg_dollar:$2530.50","3615.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","3615.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","2892.00","80","","","Percent of Total Billed Charges","neg_dollar:$2892;Percent of Total Billed Charges","3325.80","92","","","Percent of Total Billed Charges","neg_dollar:$3325.80","3615.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3615.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2422.00","3615.00",""
"ARTHROSC KNEE W MEN REP-MED&LAT","29882","CPT","20000601","CDM","360","RC","","Facility","Inpatient","","","3158","2526.40","2115.86","67","","","Percent of Total Billed Charges","neg_dollar:$2115.86","3158.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","2115.86","67","","","Percent of Total Billed Charges","neg_dollar:$2115.86","3158.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3158.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","3158.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2715.88","86","","","Percent of Total Billed Charges","neg_dollar:$2715.88","2210.60","70","","","Percent of Total Billed Charges","neg_dollar:$2210.60","3158.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","3158.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","2368.50","75","","","Percent of Total Billed Charges","neg_dollar:$2368.50","2715.88","86","","","Percent of Total Billed Charges","neg_dollar:$2715.88","2210.60","70","","","Percent of Total Billed Charges","neg_dollar:$2210.60","3158.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","3158.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","2526.40","80","","","Percent of Total Billed Charges","neg_dollar:$2526.40;Percent of Total Billed Charges","2905.36","92","","","Percent of Total Billed Charges","neg_dollar:$2905.36","3158.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","3158.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2115.00","3158.00",""
"ARTHROSC KNEE; W MEN REPAIR-MED/LAT","29883","CPT","20000669","CDM","360","RC","","Facility","Inpatient","","","2448","1958.40","1640.16","67","","","Percent of Total Billed Charges","neg_dollar:$1640.16","2448.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1640.16","67","","","Percent of Total Billed Charges","neg_dollar:$1640.16","2448.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2448.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2448.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","2105.27","86","","","Percent of Total Billed Charges","neg_dollar:$2105.27","1713.60","70","","","Percent of Total Billed Charges","neg_dollar:$1713.60","2448.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","2448.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1836.00","75","","","Percent of Total Billed Charges","neg_dollar:$1836","2105.27","86","","","Percent of Total Billed Charges","neg_dollar:$2105.27","1713.60","70","","","Percent of Total Billed Charges","neg_dollar:$1713.60","2448.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","2448.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1958.40","80","","","Percent of Total Billed Charges","neg_dollar:$1958.40;Percent of Total Billed Charges","2252.16","92","","","Percent of Total Billed Charges","neg_dollar:$2252.16","2448.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","2448.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1640.00","2448.00",""
"REM FB INTRANASAL","30300","CPT","30000001","CDM","360","RC","","Facility","Inpatient","","","143","114.40","95.81","67","","","Percent of Total Billed Charges","neg_dollar:$95.81","143.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","95.81","67","","","Percent of Total Billed Charges","neg_dollar:$95.81","143.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","143.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","143.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","122.98","86","","","Percent of Total Billed Charges","neg_dollar:$122.98","100.10","70","","","Percent of Total Billed Charges","neg_dollar:$100.10","143.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","143.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","107.25","75","","","Percent of Total Billed Charges","neg_dollar:$107.25","122.98","86","","","Percent of Total Billed Charges","neg_dollar:$122.98","100.10","70","","","Percent of Total Billed Charges","neg_dollar:$100.10","143.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","143.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","114.40","80","","","Percent of Total Billed Charges","neg_dollar:$114.40;Percent of Total Billed Charges","131.56","92","","","Percent of Total Billed Charges","neg_dollar:$131.56","143.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","143.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","95.00","143.00",""
"REM FB NTRANASAL W ANESTH","30310","CPT","30000470","CDM","360","RC","","Facility","Inpatient","","","355","284.00","237.85","67","","","Percent of Total Billed Charges","neg_dollar:$237.85","355.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","237.85","67","","","Percent of Total Billed Charges","neg_dollar:$237.85","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","355.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","355.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","266.25","75","","","Percent of Total Billed Charges","neg_dollar:$266.25","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","355.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","355.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","284.00","80","","","Percent of Total Billed Charges","neg_dollar:$284;Percent of Total Billed Charges","326.60","92","","","Percent of Total Billed Charges","neg_dollar:$326.60","355.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","237.00","355.00",""
"CONTROL NASAL HEMORRH ANT SMPL","30901","CPT","30000002","CDM","761","RC","","Facility","Inpatient","","","387","309.60","259.29","67","","","Percent of Total Billed Charges","neg_dollar:$259.29","387.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","259.29","67","","","Percent of Total Billed Charges","neg_dollar:$259.29","387.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","387.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","387.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","387.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","387.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","290.25","75","","","Percent of Total Billed Charges","neg_dollar:$290.25","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","387.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","387.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","309.60","80","","","Percent of Total Billed Charges","neg_dollar:$309.60;Percent of Total Billed Charges","356.04","92","","","Percent of Total Billed Charges","neg_dollar:$356.04","387.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","387.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","259.00","387.00",""
"CNTRL POST EPISTAX INIT","30905","CPT","30000004","CDM","360","RC","","Facility","Inpatient","","","387","309.60","259.29","67","","","Percent of Total Billed Charges","neg_dollar:$259.29","387.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","259.29","67","","","Percent of Total Billed Charges","neg_dollar:$259.29","387.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","387.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","387.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","387.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","387.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","290.25","75","","","Percent of Total Billed Charges","neg_dollar:$290.25","332.82","86","","","Percent of Total Billed Charges","neg_dollar:$332.82","270.90","70","","","Percent of Total Billed Charges","neg_dollar:$270.90","387.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","387.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","309.60","80","","","Percent of Total Billed Charges","neg_dollar:$309.60;Percent of Total Billed Charges","356.04","92","","","Percent of Total Billed Charges","neg_dollar:$356.04","387.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","387.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","259.00","387.00",""
"INTUBATION ET EMERGENT","31500","CPT","30000078","CDM","761","RC","","Facility","Inpatient","","","355","284.00","237.85","67","","","Percent of Total Billed Charges","neg_dollar:$237.85","355.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","237.85","67","","","Percent of Total Billed Charges","neg_dollar:$237.85","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","355.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","355.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","266.25","75","","","Percent of Total Billed Charges","neg_dollar:$266.25","305.30","86","","","Percent of Total Billed Charges","neg_dollar:$305.30","248.49","70","","","Percent of Total Billed Charges","neg_dollar:$248.49","355.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","355.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","284.00","80","","","Percent of Total Billed Charges","neg_dollar:$284;Percent of Total Billed Charges","326.60","92","","","Percent of Total Billed Charges","neg_dollar:$326.60","355.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","355.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","237.00","355.00",""
"CATHETER ASPIRATION NASOTRACHEAL","31720","CPT","30000008","CDM","761","RC","","Facility","Inpatient","","","180","144.00","120.60","67","","","Percent of Total Billed Charges","neg_dollar:$120.60","180.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","120.60","67","","","Percent of Total Billed Charges","neg_dollar:$120.60","180.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","180.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","180.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","154.80","86","","","Percent of Total Billed Charges","neg_dollar:$154.80","125.99","70","","","Percent of Total Billed Charges","neg_dollar:$125.99","180.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","180.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","135.00","75","","","Percent of Total Billed Charges","neg_dollar:$135","154.80","86","","","Percent of Total Billed Charges","neg_dollar:$154.80","125.99","70","","","Percent of Total Billed Charges","neg_dollar:$125.99","180.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","180.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","144.00","80","","","Percent of Total Billed Charges","neg_dollar:$144;Percent of Total Billed Charges","165.60","92","","","Percent of Total Billed Charges","neg_dollar:$165.60","180.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","180.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","120.00","180.00",""
"INSERTION OF CHEST TUBE","32551","CPT","30000011","CDM","761","RC","","Facility","Inpatient","","","1013","810.40","678.71","67","","","Percent of Total Billed Charges","neg_dollar:$678.71","1013.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","678.71","67","","","Percent of Total Billed Charges","neg_dollar:$678.71","1013.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1013.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1013.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","871.18","86","","","Percent of Total Billed Charges","neg_dollar:$871.18","709.09","70","","","Percent of Total Billed Charges","neg_dollar:$709.09","1013.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1013.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","759.75","75","","","Percent of Total Billed Charges","neg_dollar:$759.75","871.18","86","","","Percent of Total Billed Charges","neg_dollar:$871.18","709.09","70","","","Percent of Total Billed Charges","neg_dollar:$709.09","1013.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1013.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","810.40","80","","","Percent of Total Billed Charges","neg_dollar:$810.40;Percent of Total Billed Charges","931.96","92","","","Percent of Total Billed Charges","neg_dollar:$931.96","1013.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1013.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","678.00","1013.00",""
"ASPIRATE PLEURA W/ IMAGING","32555","CPT","30000293","CDM","761","RC","","Facility","Inpatient","","","1735","1388.00","1162.45","67","","","Percent of Total Billed Charges","neg_dollar:$1162.45","1735.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","1162.45","67","","","Percent of Total Billed Charges","neg_dollar:$1162.45","1735.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1735.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1735.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","1492.10","86","","","Percent of Total Billed Charges","neg_dollar:$1492.10","1214.50","70","","","Percent of Total Billed Charges","neg_dollar:$1214.50","1735.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","1735.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","1301.25","75","","","Percent of Total Billed Charges","neg_dollar:$1301.25","1492.10","86","","","Percent of Total Billed Charges","neg_dollar:$1492.10","1214.50","70","","","Percent of Total Billed Charges","neg_dollar:$1214.50","1735.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","1735.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","1388.00","80","","","Percent of Total Billed Charges","neg_dollar:$1388;Percent of Total Billed Charges","1596.20","92","","","Percent of Total Billed Charges","neg_dollar:$1596.20","1735.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1735.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","1162.00","1735.00",""
"VENIPUNCTURE AGE 3 YRS/>","36410","CPT","30000127","CDM","761","RC","","Facility","Inpatient","","","339","271.20","227.13","67","","","Percent of Total Billed Charges","neg_dollar:$227.13","339.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","227.13","67","","","Percent of Total Billed Charges","neg_dollar:$227.13","339.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","339.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","339.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","291.54","86","","","Percent of Total Billed Charges","neg_dollar:$291.54","237.29","70","","","Percent of Total Billed Charges","neg_dollar:$237.29","339.00","","","","Per diem","neg_dollar:$4432.05;105% of Medicare Per Diem Rate","339.00","","","","Per Diem","neg_dollar:$33765.58;102% of Medicaid DRG Base rate","254.25","75","","","Percent of Total Billed Charges","neg_dollar:$254.25","291.54","86","","","Percent of Total Billed Charges","neg_dollar:$291.54","237.29","70","","","Percent of Total Billed Charges","neg_dollar:$237.29","339.00","","","","Per Diem","neg_dollar:$34262.13;103.5% of Medicaid DRG Base rate","339.00","","","","Per Diem","neg_dollar:$49655.26;150% of Medicaid DRG Base rate","271.20","80","","","Percent of Total Billed Charges","neg_dollar:$271.20;Percent of Total Billed Charges","311.88","92","","","Percent of Total Billed Charges","neg_dollar:$311.88","339.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","339.00","","","","Per diem","neg_dollar:$4221;100% of Medicare Per Diem Rate","227.00","339.00",""
"ROUTINE VENIPUNCTURE","36415","CPT","30000091","CDM","300","RC","","Facility","Inpatient","","","28","22.40","18.76","67","","","Percent of Total Billed Charges","neg_dollar:$18.76","28.00","","","","Per diem","neg_dollar:$4263.21;101% of Medicare Per Diem Rate","18.76","67","","","Percent of Total Billed Charges","neg_dollar:$18.76","28.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","28.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","28.00","","","","Per diem","neg_dollar:$4305.42;102% of Medicare Per Diem Rate","24.08","86","","","Percent of Total Billed C